Inspection on 21/11/05 for Westbury Court

This inspection was carried out on 21st 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 but made no statutory requirements on the home.

Other inspections for this house

Westbury Court 30/07/07

Westbury Court 21/08/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westbury Court Westbury Court Gardens Westbury-on-severn Glos GL14 1PD Lead Inspector Mrs Ruth Wilcox Announced Inspection 21st November 2005 09:00 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 Westbury Court DS0000064610.V255978.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 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. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westbury Court Address Westbury Court Gardens Westbury-on-severn Glos GL14 1PD 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) 01452 760429 01452 760355 The Orders of St John Care Trust To be appointed Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user under the age of 65 years. This condition to be removed once the service user reaches 65 years or is no longer accommodated in the home. 16 May 2005. Date of last inspection Brief Description of the Service: Westbury Court is a purpose built care home located in the village of Westbury on Severn, and is approximately 10 miles from the centre of Gloucester. It is registered to provide personal and nursing care for 42 older people, and also has two designated respite accommodation rooms. The home is managed by the Orders of St John Care Trust. A registered general nurse is on duty twenty four hours a day. All health care services are accessible from community resources, and residents can register with one of the local General Practitioners. The home provides level access throughout, and residents are accommodated on two floors; a staircase and shaft lift provide access to the first floor. Accommodation is provided in single rooms, though a small number of rooms have an interconnecting door if wanted for couples. Each room has its own wash hand basin, and three rooms provide en-suite facilities. Bathrooms and toilet areas are numerous and easily accessible, and are spacious and fully equipped to meet the needs of less able residents. Communal areas include a smaller lounge on both floors and a large lounge/dining room and small conservatory on the ground floor. A pleasantly situated garden is at the rear of the home, and is easily accessible to the residents. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection over seven and a half hours on one day in November. The acting manager was present throughout the inspection providing assistance where requested. The home was warm and welcoming, and staff were pleasant and helpful. The availability of information about the home to assist prospective residents and their families in making their choice was looked at, as were the contractual arrangements once admitted. Care records and the previously issued requirements regarding improvement in the management of medications were inspected. The care of three residents was closely looked at in particular, and there was direct contact with fourteen residents, three visitors and five other staff. Their views regarding the standards of services and care at the home were sought wherever practicable. The arrangements for residents to make and pursue personal choices in respect of their daily lives were looked at, which also included their options for social activities. The management arrangements for the home were looked at, as were the systems for monitoring and ensuring quality of the service, and the policy for dealing with complaints. The provision of staff and the way in which they are recruited, supervised and trained was inspected. A tour of the premises took place, with particular attention to the standard of maintenance, health and safety and cleanliness. What the service does well: Westbury Court is a safely maintained, very clean and comfortable home for the residents living there. Prospective residents and their families have access to information about the home, including the necessary contractual information, ahead of their admission, in order that they can make an informed choice about moving there. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 6 There are high levels of satisfaction among residents and their families regarding the care they receive, and the staff group looking after them. Residents say that staff, although very busy, do their very best, are kind, caring and very respectful. Residents also are able to enjoy a good degree of privacy, and are able to exercise personal choices as far as possible in their daily lives. The acting manager has adopted an open door policy, ensuring that she remains accessible and approachable to residents and visitors as much as possible. There is a robust system for dealing with complaints and concerns when they arise, with evidence that there is confidence in the acting manager and staff to be receptive, to listen and be committed to addressing them. There are also good systems for monitoring the quality of the service provided at the home, with residents and their families having opportunities to give feedback on their views and ideas. Although Westbury Court does not currently have a registered manager in post, the person appointed as the temporary acting manager, has taken her role very seriously, and has done very well in terms of providing continuity for the residents and staff. She has ensured a structured approach to ensuring that the staff have been supervised and adequately supported, and has ensured the health and safety of all those living and working at the home. What has improved since the last inspection? What they could do better: Despite evidence confirming a good standard of care, there is much room for improvement regarding the written planning and documentation of residents’ care issues and needs. Some care plans inspected were not fully indicative of the care needed, and risk assessment work had not been carried out in some cases where such work was very relevant. Although the home generally adopts a safe system for managing residents’ medications, there is room for improvement with this as well, in terms of complying with regulations for the handling of unwanted medications, and certain aspects of recording. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 7 The social opportunities for residents are extremely limited, with very little happening, and some residents becoming unstimulated and bored as a consequence. Despite a committed core group of staff, who seem to care very much about the residents, there are constraints upon provision and deployment, which are affecting the quality time that staff can spend with the residents, particularly in a social sense. It is also negatively impacting on other areas of their work, with a prime example being that the service of breakfast is very late for some residents. Not only must the current staffing be reviewed, but also the established working practices of the staff group. Recruitment of staff is generally in accordance with requirements; just one omission was identified on this occasion, and those responsible for recruitment must ensure that they adhere to the requirements regarding pre-employment checks at all times. Staff have access to the NVQ training programme, but not many are qualified at this time. Fire safety training is delivered, but the records do not clearly identify that all staff have received timely training in this regard, although the acting manager is sure that they have. The environment in this home is generally very good, but at this time there are two specified carpets in residents’ rooms that require replacement. 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. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. The pre-admission information and contractual arrangements ensure that residents have access to adequate information when making their choice about the home. EVIDENCE: Prospective residents are provided with an information brochure, which informs about the home and The Orders of St John Care Trust; the information is currently under review, with a revised and more up to date Service User Guide being produced. The home’s Statement of Purpose is contained in a folder, which is easily accessible for anyone choosing to read it. This is fully reflective of the requirements in the regulations, but is also under review by The Orders of St John Care Trust. Residents are supplied with contracts on admission to the home; a sample was seen. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 10 The home also issues a copy of the terms and conditions of the home, in an ‘Accommodation Charter’ for County Council funded residents, which accompanies their Individual Service Contract from Social Services. Intermediate care is not provided at Westbury Court. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10. There is no clear and consistent care planning in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. The systems for administering medications are generally good, with isolated inconsistencies that could pose a risk to residents. Staff strive to ensure that personal support is offered in such a way as to promote the privacy and dignity of the residents. EVIDENCE: Each resident has a personal plan of care, which is subject to regular review. Much of each plan is linked to an assessment of needs, however during the case tracking exercise, there was evidence of numerous gaps in this. In the first case the following anomalies were found: • An assessment indicated that a liquidised diet and assistance to feed was needed; there was no care plan to address this • An assessment indicated that there was a continence problem; there was no care plan to address this Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 12 • • • A care plan review indicated that the person had developed a pressure sore; there was no change to the recorded action plan, in consideration that it was no longer meeting the needs A separate acute care plan in respect of the sore did not clearly identify the precise management required, though the recorded reviews made mention of a diversity of treatments The daily records included reference to an incident involving entrapment in cot sides some time ago. Although there had been no serious effects from this and there had not been a repeat of the incident, there was no risk assessment or care plan to address this possibility. In the second case the following anomalies were found: • The printed medical history indicated previous history of a suicidal tendency; there was no reference to this in a care plan at all • The accident records show the person fell; there was no falls risk assessment, and a mobility care plan was not reflective of this risk at all • An assessment shows the person is at slight risk of developing a pressure sore; there was no care plan to address this. In the third case, the case tracking exercise confirmed that the person was much more dependent than the assessment and care plans showed. The acting manager was fully aware of this, and had recently completed a new dependency assessment with a view to re-drafting a new plan of care more in line with the person’s changing needs. Although case tracking indicated that the majority of care was being delivered appropriately in these cases, the home has not adequately planned and recorded care issues in records, and in some cases has not taken certain risks into account during planning. The management of medications was not inspected in detail on this occasion, however, previously issued statutory requirements were reassessed with a view to gauging the home’s compliance. Improvements have been made to the hand written entries on medication charts, and the storage of controlled medications has also been improved. The ‘Allergies’ boxes on the medication charts have not been consistently completed, including ‘none known’ in cases where there are none. One resident was managing her own medications, and had a locked drawer for their safe storage; there was no documented risk assessment in this case. The home’s dispensing pharmacy is the local general practitioner surgery. The surgery has historically accepted the return of wasted medications from the home. These arrangements must be reviewed, as those accepting waste medications from care homes with nursing must have an appropriate license to do so. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 13 Staff were observed throughout the day being very attentive and respectful to the residents. Residents themselves spoke very positively about the standard of care they receive, with those spoken to saying things like, ‘this is a marvellous home, it couldn’t be better’; ‘We are cared for very well’. Residents said that staff knocked on their doors before entering, and were mindful of their privacy. One person said that staff ‘respect her room’. The three visitors all were most enthusiastic about the standard of care their relative was receiving, and that as far as they could tell, the staff were very respectful of their relative personally, and their private space. They indicated that the staff ‘go out of their way’ to be helpful. One of the visitors commented that she would ideally like to see a separate small lounge that could be used for visiting in private, rather than always having to go to her relative’s room to have privacy; this visitor merely mentioned this, and in no way wished to complain about it. This person also said that there had been an occasion when her relative had been dressed in clothing which did not belong to her; it had inadvertently been put into the wrong wardrobe on return from the laundry. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14. There are very limited social opportunities for residents, resulting in lack of stimulation for them and boredom for some. Respect is shown to residents’ personal choices, in order that they maintain some control over their lives where possible. EVIDENCE: There is very little happening socially on a structured or regular basis at Westbury Court. There are some planned events such as seasonal entertainments, and religious services, and an occasional spontaneous event, such as a quiz. Residents were seen sitting in various parts of the home, and appeared to be totally unstimulated, apart from the television being on, and one or two reading their newspapers or books. At least six residents said that they were bored, and that there was nothing to do at all. One resident said she would like to do walking exercise, but due to the constraints on the busy staff time, was unable to pursue this activity. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 15 Two visitors said that there was very little for their relative to do to occupy them. One said that there is a good entertainer occasionally, but other than that there is not much on offer. Respect is shown by staff towards residents being able to pursue personal choices and maintain some control in their lives. This is evident in that residents are able to manage their own affairs if they are able, and in the way they can personalise their rooms, and select favourite choices of food. Residents in the main confirmed that they feel respected, with one or two saying that they can do what they like. Visitors said much the same, and appreciated the efforts that staff made to enable their relatives to make choices. However, in view of a small number of comments, it was evident that some residents feel unable to pursue certain choices, and these mainly related to opportunities for social interactions as reported above. A small number of residents were seen having their breakfast at 11.00am; not only had these residents gone without food from the previous night, but their lunch meal was due to be served just 1.5 hours after. This was apparently these residents’ choice to eat breakfast in the dining room, but due to the staff time constraints it was proving difficult to assist these residents to wash, dress and get to the dining room in a timely way for breakfast. This issue is further reported under the staffing standard. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. EVIDENCE: A copy of the complaints procedure was clearly displayed for anyone wishing to read or use it. Residents confirmed that staff are very attentive to them, with some saying that staff will do what they can to help them. Visitors had very high levels of confidence in the staff and acting manager to respond quickly to any concerns raised, and to take any corrective actions necessary. The home maintains a record of complaints and concerns received. The record contained evidence of one complaint received since the last inspection, which had been robustly addressed. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. The standard of the environment within this home is generally satisfactory, and provides residents with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: Westbury Court provides a safe, comfortable and well maintained environment for the residents living there. A maintenance person is employed, and a rolling programme of redecoration is carried out, with the kitchen and some bedrooms having been done since the last inspection. A new call bell system has been installed for the residents. During a tour of the building it was noted that in two bedrooms, which were identified to the acting manager at the time, the carpets were old, worn and stained. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 18 Residents were saying that the ground floor lounge was a bit cold for them, and the maintenance person was present sorting out the radiators in there to improve things for them. One visitor said that his relative would like her room to be carpeted, as it had alternative type flooring; the acting manager agreed to address this straight away. Another visitor said that she and her relative appreciated the attractive and accessible gardens. Another visitor commented on how clean and comfortable the environment was. The home is cleaned to a good standard, and was odour free throughout the visit. Laundry and clinical waste is safely managed, with due regard to infection control procedures. Gloves and aprons, liquid soap and paper towels are provided throughout the home. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29. Staffing provision and deployment is not adequate to meet the needs of the residents in the most appropriate way. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents, however any failure to observe these consistently could pose some risks. The home encourages care staff to undertake a care qualification, in order that they can fully understand their roles. EVIDENCE: Staff rotas demonstrate the provision of nursing, care and ancillary staff. It is the routine for there to be one nurse on duty at all times, with seven carers in the morning, six carers during some of the afternoon and evening, and two overnight. Rotas also show that there has been significant usage of agency and peripatetic staff, though the acting manager has been recruiting in an attempt to reduce such usage. On closer scrutiny of the rotas, and from speaking with residents, visitors and staff themselves, the deployment of staff is causing certain times when staff struggle, despite their very best efforts, to meet all residents needs in the most appropriate and timely way. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 20 The habit has been for there to be a reduction in care staff from 1pm until 2.30pm, and for possibly two of the late shift staff not to come on duty until 4pm. This arrangement is leading to a gap in the staffing, which all are finding difficult to contend with. Furthermore, one of the morning carers and one of the evening carers is being removed from care duties in order to work in the kitchen or dining room, which is further depleting the number of care staff available for the residents. Although residents and visitors cannot speak highly enough of the staff group at Westbury Court, saying that they are so kind, caring, patient, approachable and helpful, they do indicate that staff are too busy to spend much time with them, with one visitor expressing concern about the depletion of staff at certain times. One resident said that he felt the home was very short staffed, and that he had been kept waiting a long time for things. Further to reporting under standard 14 regarding residents’ choices, it was clear that a review of staff’s working practices is needed in the mornings, in respect of serving breakfast and managing the personal needs of individuals as well. More timely and appropriate practices must be established so that all residents can receive their breakfast meal at a suitable time. Staff themselves appear to be a very hard working and committed group, with those who were spoken to indicating their ‘love of their job’. However, it was very clear that they are aware of the challenges they have to face with the current deployment, and persistently feel they are compromised by it. The home currently only has three care staff qualified to NVQ level 2 standard, though has a further two carers who are near to completing their award. It was reported that a recently recruited carer who is due to commence work in December, already has the award. This number of qualified carers is evidently not near the 50 target that should be achieved by the end of this year, though the home will continue to make all efforts to work towards achieving it in the future. A random selection of staff files was chosen for inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in the files. There was just one exception to this however. One of the staff had previously worked with vulnerable adults in her last position. On this basis the home should have sought written verification of the reason why she had ceased to do so; this had not been sought at the time. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38. There are good management systems in place to ensure that the health and safety of the residents is safeguarded. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. EVIDENCE: The home has not had a registered manager for some months now; arrangements to appoint a suitable person have proved to be slower that the home would have liked, but are progressing. In this interim period, the home has been fortunate to have an experienced and committed acting manager, who has done very well in terms of providing leadership and guidance to the staff, and reassurances and support to the residents and visitors. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 22 The Quality Assurance Manager for the Orders of St John Care Trust provides support to the home in terms of the internal quality monitoring systems, and has been overseeing the introduction of a new raft of policies and procedures. The home is currently being audited as they work towards the quality management standard, ISO 9001. Meal monitoring forms have been introduced on a frequent basis, in order that residents’ views about the quality of the food can be obtained. The acting manager also carries out accident monitoring regularly. A report has not yet been produced on the basis of all the quality monitoring work that is being carried out, but this is apparently being addressed by The Orders of St John Care Trust. It was reassuring to know that residents and their families had been informed of this inspection, and that some families had chosen to make a special effort to discuss their experiences of the home. Residents and their visitors appeared confident in the acting manager and staff to do all they could to address any concern they might have, and would be receptive to any of their comments. The acting manager has made a good start on a formal and structured staff supervision programme. Records indicate that staff have received formal supervision at least once since the acting manager started, and have received an annual appraisal also, as part of the programme. Supervision has covered practice issues and developmental needs. There was evidence that health and safety issues are addressed well in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. The frequency of fire safety training for all staff was not entirely clear from the records, though the acting manager did say that all staff are included in the regular training sessions. There are five members of staff currently qualified to provide First Aid. All necessary safety checks and maintenance of equipment is undertaken in a timely fashion. Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 23 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 3 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x x 3 x 2 Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 24 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 OP1 Regulation 4(2) 5(2) Requirement The home must send the revised copies of the Statement of Purpose and Service User Guide to the CSCI upon completion. Staff must record care plans which clearly demonstrate how residents’ needs in respect of their continence needs are to be met. (previous timescale of 30/06/05 not met) Staff must record care plans which clearly demonstrate how residents’ needs in respect of any dietary requirements and wound management are to be met. Staff must ensure that care plans for managing a pressure sore are amended on the basis of reviews, so that they provide clear guidance on how to carry out the care needed. Staff must conduct and record risk assessments for those residents who are at risk of injury from cotsides and from falling, with associated care planning to reduce risks DS0000064610.V255978.R01.S.doc Timescale for action 30/04/06 2 OP7 15(1) 31/12/05 3 OP7 15(1) 31/12/05 4 OP7 15(2.c) 31/12/05 5 OP7 13(4.c) 15(1) 31/12/05 Westbury Court Version 5.0 Page 25 6 OP7 15(1) 7 OP7 12(1.b) 15(1) 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP12 16(2.n) 12 13 OP19 OP27 23(2.b) 21(2) 18(1.a) 14 OP27 16(2.i) recorded. Staff must devise care plans for all residents who are assessed as being at risk of developing pressure sores. Staff must ensure appropriate care planning to address a resident who has been identified as previously having a tendency to self-harm. Staff must ensure that appropriate information, including if ‘none known’, is recorded in the ‘Allergy information’ boxes on medication charts. Staff must conduct and record risk assessments for those residents wishing to manage their own medications. The registered person must ensure that the arrangements for the disposal of waste medicines are in accordance with the Special Waste Regulations 1996. (Reference: The Environmental Agency) The home must consult with residents about a programme of social activities, and provide a programme that will meet their needs. The home must replace the carpets in the 2 identified bedrooms. In consideration of residents and staff statements, the registered person must ensure that a complete review of staffing provision and deployment is undertaken, and that the necessary action is taken to ensure staffing is adequate to meet residents’ needs efficiently. A review of staff working practices must be undertaken, with any necessary action taken, to ensure that residents receive DS0000064610.V255978.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/01/06 28/02/06 31/03/06 31/01/06 31/01/06 Westbury Court Version 5.0 Page 26 15 OP29 19, Sch 2 16 OP38 23(4.e) their breakfast meal at a more suitable time. In cases of applicants for care work, who have worked with vulnerable adults in their last position, the home must obtain written verification of the reason why they ceased to work in such a capacity. The home must ensure that fire safety training consistently encompasses all staff, with full records of those attending maintained. 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westbury Court DS0000064610.V255978.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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