Inspection on 10/01/07 for Westbury House Nursing Home

This inspection was carried out on 10th January 2007.

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 House Nursing Home 23/05/07

Westbury House Nursing Home 08/11/05

Westbury House Nursing Home 12/07/05

Westbury House Nursing Home 04/01/05

Westbury House Nursing Home 13/07/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Westbury House Nursing Home West Meon Nr Petersfield Hampshire GU32 1HY Lead Inspector Nick Morrison Unannounced Inspection 10th January 2007 11.00 X10029.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 House Nursing Home DS0000011525.V329450.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 and 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. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbury House Nursing Home Address West Meon Nr Petersfield Hampshire GU32 1HY (01730) 829511 (01730) 829108 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 Irvine Navid Naqvi Mrs Linda Murray Care Home 70 Category(ies) of Physical disability (70), Physical disability over registration, with number 65 years of age (70) of places Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Other than one service user admitted on the 27/11/06, no service user is to be admitted over the age of 70 8th November 2005 Date of last inspection Brief Description of the Service: Westbury House is a care home situated on the edge of the rural village of West Meon. The home is registered to provide accommodation and nursing care for up to seventy service users, though at the present only up to fifty service users are accommodated at any one time. The home caters for persons that have an acquired brain injury or an illness affecting the nervous system. The home has an occupational therapy facility and a facility for service users to purchase private physiotherapy. The registered manager has recently left the home. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 10th January 2007 and lasted six hours. During this time the Inspector toured the premises, looked at a sample of six service users’ files and met with three of those people. All records and relevant documentation referred to in the report was seen on the day of inspection. The Inspector spoke with the management team, as well as a sample of staff and other service users. What the service does well: 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. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 and 6 (Older People) and NMS 2 (Adults 18 - 65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs assessed prior to admission. The home does not provide intermediate care. EVIDENCE: Service users’ files showed that assessments of need were completed with service users and their families prior to them moving into the home. Service users spoken with confirmed that they had been involved in the assessment process. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 8 The home does not provide intermediate care. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9 and 10 (Older People) and NMS 6, 9, 16, 18, 19 and 20 (Adults 18 - 65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs recorded in a care plan and from having their healthcare needs met. They are protected by the home’s medication policy and practices and benefit from being treated with respect. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 10 EVIDENCE: Care plans were in place for all service users. The care planning process was comprehensive and covered a full range of need areas. Care plans seen during the visit were well written and were clear about what each person’s needs were and what staff needed to do in order to meet them. The individual care plan format was clear and files were laid out so that they were easy for staff to use. The files also contained ongoing assessments so that the needs of service users could be monitored and so that changing needs could be responded to appropriately. There were nutritional and activities profiles in each service user’s file, but most of these had not been completed. One section in the service user files was used to monitor and record the health needs of each person. These were up-to-date and demonstrated that healthcare needs were regularly monitored. Where concerns about healthcare needs had been identified, there were records of the follow up action that had been taken. Service users were supported to access relevant healthcare services as necessary and service users spoken with confirmed that staff arranged appointments and supported them to attend when necessary. The home had a clear medication policy in place to protect service users. Only senior staff administered medication and the Duty Officer each day was responsible for administering the medication. Records showed that all staff involved in administering medication had received appropriate training and staff spoken with confirmed that the training they received was in depth and of good quality. On the day of the inspection visit, the midday medication was administered during the lunchtime period and the person administering the medication demonstrated an understanding of the policy and an awareness of the need to administer medication in a safe and sensitive manner. Each service user was given their medication discreetly. The member of staff observed that it had been taken before signing it off. Observation was done from a distance so that there was no need to stand over each person while they took their medication. The medication was stored in a methodical and safe manner in the medication cupboard and a colour coding system was used to decrease the likelihood of mistakes being made. There were no recorded errors in the administering of medication and staff spoken with said they were not aware of any errors that had been made. The medication records were clear, up-to-date and accurate. Observation throughout the visit showed that staff were very good at demonstrating respect towards service users. Staff always appeared to knock on service users’ doors before entering their room and always spoke with service users in a respectful manner. Staff had received training in supporting service users in a respectful way and providing care in the way people preferred it. Staff spoken with were clear about the need to ensure the rights of service users were upheld and of the need to respect peoples individuality. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 11 Service users spoken with said that staff always treated them well and that they felt comfortable with the staff in the home. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 and 15 (Older People) and NMS 12, 13, 15 and 17 (Adults 18 - 65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having control over their own lifestyles and are able to take part in social activities and maintain contact with friends and relatives. They also benefit from having a well-balanced and varied diet. EVIDENCE: Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 13 The home organises a variety of social activities for service users, although there is no set programme of activities. Some activities are organised on a regular basis for individual service users and other, group activities are organised periodically. Service users spoken with were aware of the activities on offer and of how to get involved in different activities if they wanted to. Records were kept of all activities service users were involved in. There were regular church services within the home as well as art and craft activities that took place in a dedicated area in the basement. The local college were also involved in arranging specific activities for service users. Activities the home arranged for service users in the past year included picnics, theatre trips and a sailing trip. The home has a visitors’ policy that encourages visitors to come to the home at any reasonable time. Service users spoken with were aware of the visitor’s policy and said that they could receive visitors whenever they wanted to and were able to meet with them in private. They also said that their visitors were made to feel welcome within the home and that staff supported them in entertaining their visitors. Service users spoken with felt they had as much control as possible over their lives and were able to make their own decisions. Care plans emphasised the need for staff to support service users in making their own decisions. The decoration and organisation of service users’ rooms, their choice of activities and their own relationships demonstrated that service users were able to make choices about their own lifestyles. The food provided in the home appeared to be of good quality and service users said that they had adequate amounts of food available throughout the day. Both the lunchtime and the suppertime on the day of the inspection visit were sociable occasions and provided a comfortable and pleasant atmosphere. Support was available for those service users who required it and they were able to choose to eat in the dining room or in their own rooms. Some service users also had facilities in their room for making themselves snacks. The home has a six weekly menu that is currently being updated with input from service users. The menu demonstrated a variety of healthy food was offered and that service users had choices about their meals. The kitchen provided food both for the home and the adjacent conference facilities and all food appeared to be well prepared using fresh ingredients where possible. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 (Older People) and NMS 22 and 23 (Adults 18 - 65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were partially protected by the home’s abuse policies and practices and were confident that any complaints they had would be responded to. EVIDENCE: The home has a complaints policy in place that clearly explains to service users how they can make a complaint if necessary. A copy of the policy is given to each service user on admission and further copies are posted throughout the building. The policy is straightforward and makes it easy for service users to voice concerns. Service users spoken with said they were aware of the policy and the procedure for making a complaint and felt that the home would take any complaints seriously and respond to them. The home has a system in place for recording all complaints, but it was not a very thorough system. The manager was aware of this and is in the process of revising it so that complaints and the responses to them are recorded systematically. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 15 There is a policy in place for the protection of service users from abuse of any kind. There had been a requirement from the previous inspection report that all staff must receive training in the protection of vulnerable adults Staff training had begun to take place and a programme was in place for all staff to receive this training. Staff spoken with demonstrated some awareness of potential abuse issues and of how they should be reported. The management team were aware of the local adult protection procedures and how to report concerns under these procedures. Some incidents of aggression towards service users from other service users had been reported under these procedures, but there was evidence that further incidents had taken place that had not been reported. The Inspector advised the management team that all such incidents must be reported. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19 and 26 (Older People) and NMS 24 and 30 (Adults 18 - 65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from living in a cleaner and more hygienic home. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 17 EVIDENCE: There had been a previous recommendation that the basement area should be redecorated to create a pleasant environment for resident’s accessing that area. Work had begun on this but the area still needs further work. A number of service users in the home smoked and smoking was restricted to one half of the lounge area. Unfortunately, smoke permeated from here into the rest of the lounge and also into the adjacent dining room. Some service users were unhappy about this and a resolution needs to be achieved whereby smokers have somewhere comfortable to smoke without affecting other service users in the home. Despite the fact that the home employs three to four domestic staff throughout each day, the home is not kept as clean as it ought to be. The fact that the home is a very large and old building makes the maintaining of cleanliness difficult, but the home needs to overcome this in the interests of service users. Issues highlighted to the management team on the day of the inspection visit included a very dirty sink in the laundry area, a filthy floor in the downstairs shower room, windows that were so dirty as to actually obscure the view in some rooms, enamel baths that were severely worn down to the metal, high level cleaning throughout the building had not been attended to and there were a lot of dust and cobwebs, window sills were dusty and contained cobwebs and dead flies and moths and there were stains on some of the carpets which had obviously been there for some time. The management team did acknowledge all the above as being issues and were obviously concerned about addressing them as soon as possible. The issues generated a lot of discussion amongst the management team along with thoughts about the reasons for the lack of cleanliness and ideas about how it might be tackled. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28, 29 and 30 (Older People) and NMS 32, 34 and 35 (Adults 18 - 65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefited from being supported by adequate numbers of well trained staff and were protected by the home’s recruitment policies and practices. EVIDENCE: The home had recently suffered from a sudden loss of staff and had been relying on agency staff. The management team were aware of this and had taken steps to recruit new permanent staff and decrease the amount of agency staff used. In the week of the inspection visit there were only eight occasions where agency staff had been used. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 19 The home employs eight care staff each morning and seven each afternoon. In addition there were two trained members of staff on duty. At night there were three care staff on duty with the two trained staff. Domestic, laundry and kitchen staff were in addition to the care staff team. Rotas showed that sufficient staff were on duty at all times during the week. The number of staff on duty at the time of the inspection visit corresponded with the numbers shown on the rota. Staff spoken with said that there were usually enough staff on duty to ensure that the needs of service users were met. Service users spoken with confirmed that staffing levels were adequate in their opinion. Staff were receiving training in a wide range of areas related to the needs of service users. Service users spoken with felt that the staff in the home received adequate training in order to meet their needs. Recruitment records demonstrated that all necessary pre-employment checks were undertaken prior to staff beginning work in the home. These included Criminal Records Bureau checks, references and work permits for non-EU staff. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 33, 35, 36 and 38 (Older People) and NMS 37, 39 and 42 (Adults 18 - 65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 21 Service users would benefit from the home being managed more closely around their own interests and by being supported by staff who were regularly supervised. EVIDENCE: The Registered Manager has left the home and new management arrangements are being put in place. The new arrangements are based on one member of the management team being the Registered Manager and being supported by a trained member of staff who will be responsible for the care practices in the home. There was some discussion during the inspection visit about how this might work and what criteria needed to be met in order for this to be acceptable as far the registration process is concerned. The home has some quality assurance processes in place, but these were mostly to do with processes and lacked input from service users about the quality of the service they received. There were staff questionnaires in place and some evidence that these were used in improving the quality of the service. The Inspector discussed the need for the quality assurance processes to be based around the views of service users and how feedback from service users might be used to improve the service. The management team were aware of this and planned to revise the quality assurance processes accordingly. The system for assisting service users with their finances was based on all service users having their money in one central account. It was explained that the reason for this was that it would be very difficult and time-consuming to support individual service users to use their own separate accounts and that doing so might seriously affect the amount of social opportunities for service users. However, the use of one single account for all service users is contrary to the Care Homes Regulations 2001 and the home must find an alternative to this. The accounting of individual service users’ money within the current system is good and records were kept of all transactions and the amount of money each service user had. Clear records wee kept both on paper and electronically. These were constantly monitored and compared and any discrepancies were highlighted immediately and action taken to rectify them. Staff administering the system were responsive to enquiries from service users about their own finances. On the day of the inspection visit one service, in passing, asked a member of staff how much money she had and the member of staff immediately looked up the records and reported back to the service user. Service users spoken with felt they had as much control over their own finances as they wanted or were able to have and that they had access to their Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 22 money whenever they wanted to. Service users were also involved in the records of their own money and signed for any expenditure. There had been a requirement from the last three inspection reports that all staff must receive support and supervision at least six times a year. This has still not been achieved, but a system has been put in place to ensure this and supervision has begun with some staff. Whilst this represents an improvement, there is still need to fully implement the new system and maintain levels of staff supervision on an ongoing basis. Health and safety in the home was well managed. Staff received regular health and safety training and workplace risk assessments were in place and regularly monitored and reviewed. Records demonstrated that health and safety in the home is consistently monitored and managed. Records were kept of all servicing of equipment and good fire records were also kept. A workplace health and safety risk assessment was in place and was regularly reviewed. Information was kept on all substances that are potentially hazardous to health. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 2 34 X 35 2 36 2 37 X 38 3 Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 24 YES 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 YA23 OP18 Regulation 13(6) Requirement The registered person must ensure that all staff receive training about the protection of vulnerable adults. THIS REQUIREMENT WAS PREVIOULSY MADE ON 12/07/05 AND 8/11/05. The registered person must facilitate smoking for those service users who want to while ensuring it does not impact on other service users. The registered person must implement a programme to improve and maintain adequate levels of cleanliness and hygiene within the home. The manager must submit an application to be registered. The registered person must ensure that service users do not share bank account facilities. Timescale for action 30/05/07 2. YA24 OP19 12 31/03/07 3. OP26 YA30 23 10/01/07 4. 5. OP31 YA37 OP35 YA23 8 20 31/03/07 31/03/07 Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 25 6. YA36 18 The registered person must ensure that all care staff receive formal supervision at least six times a year. THIS REQUIREMENT WAS PREVIOUSLY MADE ON 14/01/05, 12/07/05 AND 8/11/05. 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 OP33 YA39 Good Practice Recommendations Work on the basement area should be completed to create a pleasant environment for resident’s accessing that area. The quality assurance system needs to be broadened to include input from service users. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Westbury House Nursing Home DS0000011525.V329450.R01.S.doc Version 5.2 Page 27 - 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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