CARE HOME ADULTS 18-65
Westbury Lodge 130 Station Road Westbury Wiltshire BA13 4HT Lead Inspector
Tim Goadby Unannounced Inspection 13th December 2005 09:10 Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 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 Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Westbury Lodge Address 130 Station Road Westbury Wiltshire BA13 4HT 01373 859999 01373 864512 westburylodge@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes (No. 2) Limited 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) Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Only the one named service user, referred to in the application dated 9 August 2005, may be in receipt of care due to having been assessed by a person qualified to do so as suffering from a diagnosed clinical mental illness necessitating care and/or treatment. 28th June 2005 Date of last inspection Brief Description of the Service: Westbury Lodge provides care and accommodation for nine adults who have a learning disability. Some service users also experience difficulties associated with sensory loss. The home is owned by Parkcare Homes Ltd, a division of Craegmoor Healthcare, who own a group of homes both locally and across the country. Accommodation in the home is provided over two floors, with seven bedrooms on the first floor, and one bedroom and a semi-independent flat downstairs. The ground floor also has a sitting room, dining room, kitchen, and laundry. All persons accommodated on the first floor must be able to climb stairs without assistance, as a lift is not provided. There is a secluded and secure garden at one side of the building. The home is situated on the edge of a residential area, about ten minutes walk from the centre of Westbury. Bus stops and a main line station are a few minutes walk away. A small car park is available at the front of the building, with a driveway onto a busy road. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in December 2005. A total of 4.25 hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; discussions with service users, staff and management; survey of service users, relatives and professionals. What the service does well:
There is a clear focus on promoting service user choice and independence. People have the opportunity to maintain existing skills, and develop new ones. This enhances quality of life, and helps individuals to work towards their personal goals. Service users have their social and recreational needs met. A range of activities are offered, both at home, and elsewhere. These are based around the known preferences of individual users. Key events, such as someone’s birthday, are marked with specific sessions designed to be enjoyable to them. Service users are supported to address their health care needs effectively. People have a variety of physical and mental health needs. These issues are set out in their individual plans. There are systems to monitor and record any key indicators. Other relevant professionals are involved in reviewing and evaluating care. Service users receive a range of regular health checks. Service users are protected by effective recruitment and selection practices. Craegmoor’s process follows all the necessary stages, including obtaining proofs of identity, written references, and criminal record checks. All required recruitment checks are completed before new staff take up post. Service users benefit from the support of appropriately qualified staff. Westbury Lodge is above the 50 target for care staff with NVQ qualifications in care. Four of the home’s current staff have achieved NVQ awards at Level 3, and another three people have completed Level 2. Another person is due to finish the latter award in January 2006. More staff are then due to start the training. Comment cards were completed by two service users before this inspection. In one case the person would prefer to live elsewhere, so they could be more independent. This is clearly documented in their own records, and various meetings have taken place to discuss the possibility of them being able to move on. Apart from this reservation, feedback from both service users is
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 6 positive about the service provided at Westbury Lodge. Both feel safe and well cared for. Comment cards were also received from two relatives of service users. Again feedback is largely positive. Both are satisfied with the overall care at the home. One comments that “The home is well run by a caring and dedicated staff.” A comment card from one professional who has contact with the home also indicates satisfaction with the care. What has improved since the last inspection? What they could do better:
There is one unmet requirement from the previous inspection. Risk assessments and management strategies are not clearly in place for all identified issues for the home’s service users. This places some individuals at risk of harm. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 7 Service users need to be confident that quality assurance measures reflect their aims and outcomes. The current service development plan lacks such a focus, as there are no goals based on input from service users. The plan also needs to have timescales against which development targets are to be evaluated. This should tie in with a minimum annual frequency of internal audit of the service. Care plans cover the necessary range of information. But further developments would enhance their quality, and ensure that each service user receives the most effective support for all their needs. Not all guidance on how to support service users is set out in sufficient detail. Information is also presented in a way which does not aid easy recognition of the most relevant current material. Nor are linked documents always clearly cross referenced. Practices for the administration and recording of medication could be improved, to provide greater protection for service users. If the home’s own staff need to make alterations to administration record charts, these should be signed and dated; and also clearly linked to the prescribing instructions. Copies of individual guidelines for the use of ‘as required’ medications should be kept in the main medication folder, for ease of reference. Although Westbury Lodge’s service user group are generally able to mobilise independently, staff may have to give some physical support and guidance at times. As a result of this, the home could usefully develop knowledge and skills within the staff team about suitable moving and handling techniques. This will ensure that service users are supported as safely and effectively as possible. 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 Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Prospective service users have their needs assessed, so they can be confident the home will be able to provide the support they require. Service users have their needs and aspirations met by the home. EVIDENCE: The home has returned to full occupancy since the previous inspection, with the admission of one service user in August 2005. The individual appears to have settled in well. The rest of the group at Westbury Lodge have lived there for some time. The new admission was previously living in another care setting in a different part of the country. Staff from Craegmoor carried out a number of visits to meet and get to know the person in their previous home. A documented assessment was carried out using the organisation’s own format. Information was also obtained from the service user’s former placement, and an assessment and care plan drawn up by the individual’s care manager. After the person moved in, an initial placement review was held after four weeks. Staffing levels have been adjusted to reflect the increase in service user numbers. Waking staff support is available across the whole 24 hour period, recognising the needs of various individuals. The home’s own staff have received training to assist them in supporting the group. A range of relevant
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 10 professionals are also consulted, to assist with devising strategies for individual service users. In one case, a person’s mental health needs are as significant as their learning disability. They receive support in respect of both aspects. The placement is felt to be meeting their needs well. The home’s registration categories have been varied to recognise the care that is being provided. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service users have their abilities, needs and goals reflected in their individual plans. But these need to develop content and presentation, so that they work effectively to ensure that all service users receive the support they need. Service users are placed at risk of harm by a failure to have clearly recorded assessments and management strategies for all areas of risk. EVIDENCE: Sampled files show that care plans are in place, and are kept under review. Input and advice is accessed from other professionals, where relevant. Issues identified as being in need of attention at the previous inspection, in June 2005, have been followed up, with evidence of benefits for the service user concerned. Some information is not set out in sufficient detail. For instance, guidance on staff interventions may be set out as statements, such as “protect from financial abuse”, without any further definition of how to do so. In another example, guidance on supporting someone in the area of diet and weight has not been broken down into objective steps, to promote a consistent approach.
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 12 The presentation of care plans is also in need of attention. Some information is duplicated unnecessarily. For instance, one person has two care plans regarding their morning routine, which say virtually the same thing. In other cases, linked material is not filed together. Craegmoor is working nationally on a new person-centred planning format, which is to be introduced from January 2006 onwards. Risk assessments and management strategies are in place, but are not yet meeting all necessary criteria. The home’s format includes a space for documents to be signed up to by all relevant people, such as the service user or their representative, and other professionals involved. But this has not been done, so there is no evidence of appropriate sharing of key decisions, on issues such as restrictive interventions. A risk assessment for one service user concerns the possibility of aggression towards them by others, which might result as a consequence of the person’s own behaviour. There is guidance about what to do if an incident has occurred. But there is no strategy set out regarding prevention and the minimising of risk. The same person was the subject of an investigation earlier in 2005 regarding their conduct towards another resident of Westbury Lodge. No risk assessments or management strategies can be shown for the relevant issues. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15 & 16 Service users have the opportunity to maintain and develop skills. Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. EVIDENCE: Service users are supported to maintain and develop skills wherever possible. In particular, accommodation for one person is provided in a semi-independent flat. The individual needs the possibility of access to staff support at all times, but can cope with many aspects of daily living, both at home and outside, without assistance.
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 14 Abilities and needs vary within the service user group. Guidelines set out the various approaches used by staff to support each individual. For instance, not all residents of Westbury Lodge have good verbal communication skills. So other techniques are used to aid effective communication, such as signing. Some people attend college courses or other day service facilities for part of the week. At other times, service users are supported in activities, both at home and in the community, by Westbury Lodge’s own staff. The service has an activities co-ordinator who leads on this, but all staff get involved. Outside the home, there is regular use of various local amenities, such as shops and pubs. This inspection took place in the period leading up to Christmas. All service users were receiving the opportunity to go out for a meal. A party was also to be held at another local Craegmoor service, which people from Westbury Lodge would be attending. Some service users have proved more difficult to engage in activities outside the home. This may be linked to mental state, anxieties or phobias. Appropriate support is accessed to try and help people work through these difficulties. There is information in service users’ care plans about their key relationships, and how these contacts are maintained. Most people have regular arrangements for keeping in touch with relatives, through visits, letters and phone calls. Information about service users includes clear details about any issues in forming relationships with them. The importance of taking care to establish an effective rapport is well set out. Comment cards from two relatives of service users contain mainly positive feedback. One person felt they could be kept better informed and consulted about the care of their family member. If it is considered important to have a degree of routine for some service users, the reasons and benefits are set out in their care plans. Some restrictions are in place, linked to the needs of service users. For instance, arrangements for monitoring some individuals, and rationing access to cigarettes. The exits from the home are on a keypad lock, for safety reasons. The property is situated near a busy road, with limited visibility in both directions. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 Service users are supported to address their health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. This could be enhanced by improvements in recording; and the availability of information. EVIDENCE: Service users have a variety of physical and mental health needs. These issues are set out in their individual plans. There are systems to monitor and record any key indicators. Other relevant professionals are involved in reviewing and evaluating care. The home has good links with its local GP surgery. A specialist consultant in learning disability also gives regular support to the home, including reviews of service user medication. Mental health professionals are involved closely for those people who need this. Sampled records show that service users receive regular health checks in all relevant areas. This includes input from dentists, opticians, and a chiropodist. All current service users have medication prescribed. One person is able to manage this themselves, with some support. The rest of the group all have their medication stored and administered by staff. All care staff undertake this
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 16 task, once they have received relevant training. This includes instruction from a suitable health professional about the specific administration technique for one drug that people might require. Arrangements for medication storage and recording were checked during the inspection. These are generally appropriate. Drugs are stored securely. The medication folder includes a photo of each service user, and information about the drugs which they take, including the likely effects. Administration records are maintained accurately. Most medication is supplied from the pharmacy in a monitored dosage system. This means that tablets and capsules are portioned out, according to the times that they are due to be taken. Drugs which cannot be supplied in this format, such as liquids, are dispensed in individually labelled containers. Each supply of medication is accompanied by a pre-printed administration record chart. When it is necessary to make alterations or amendments, the home draws up a separate sheet. These records are not signed or dated. Nor are they cross referenced to information about who has given the new prescribing instructions. Some drugs are prescribed to be given ‘as required’. This means that staff need to make a judgement about when it is appropriate to give the medication. There are guidelines in individual service user plans which set out the criteria for making these decisions. The guidelines are not currently kept in the main medication folder, which would be useful for ease of reference. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. They were met at the previous inspection. EVIDENCE: Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Service users benefit from living in a home that is kept clean and hygienic. EVIDENCE: The home was clean and hygienic in all areas seen during this unannounced inspection. One member of staff works ten hours each week, split over three shifts, specifically as a cleaner. This enables them to focus on more intensive cleaning tasks. At other times, the rest of the care team are responsible for all cleaning. Service users may also participate, depending upon their abilities and preferences. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: There has been some staff turnover since the previous inspection in June 2005. A number of new care staff have been appointed. A new person has also taken up the post of activities co-ordinator. One employee is working a mix of care and cleaning hours. The home now operates on three staff per shift throughout daytime hours, since the return to full service user occupancy. Night cover is provided by two waking staff. Agency workers are used to maintain cover if necessary, but the necessity for this has reduced recently. Craegmoor’s recruitment process follows all the necessary stages. Advertising, interviewing and selection are carried out locally. The organisation’s central human resources department then carries out the full range of employment checks, before a provisional job offer can be confirmed. These include obtaining proofs of identity, written references, and criminal record checks. Sampled staff records at this inspection show that all required recruitment checks are completed before new staff take up post.
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 20 One of the home’s senior support workers acts as training co-ordinator. Records are maintained, showing what courses each staff member has undertaken. Westbury Lodge is above the 50 target for care staff with NVQ qualifications in care. Four of the home’s current staff have achieved NVQ awards at Level 3, and another three people have completed Level 2. Another person is due to finish the latter award in January 2006. More staff are then due to start the training. A requirement of the previous inspection, for staff to receive training in supporting the mental health needs of one service user, has been met. A session was provided in August 2005 by local professionals, covering a range of introductory information. A similar session also took place before the home’s newest service user moved in, covering topics relevant to them. Staff attend a two day course on crisis prevention, which assists in the management of any behavioural needs. There are one day refresher sessions for this as well. Training already booked for 2006 includes medication, infection control, fire safety, food hygiene, equal opportunities, and protection from abuse. Most of these sessions will take place in house. Again, relevant external speakers are used where appropriate. Craegmoor also has its own training department. Service users at Westbury Lodge generally have good mobility, but may need some physical support and guidance from staff at times. As a result of this, the home could usefully develop knowledge and skills within the staff team about suitable moving and handling techniques. A new approach to induction and foundation training has just been implemented across the organisation. This links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with a learning disability. Successful completion of this package also provides workers with a pathway into NVQ training. New staff are assigned a ‘supportive colleague’ who will shadow and assist them during the early stages of their employment. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Quality assurance measures need to be revised, to ensure the home is conducted and developed in line with service users’ needs and preferences. EVIDENCE: Westbury Lodge’s registered manager left the home shortly before this inspection took place. The home’s deputy manager, Mrs Gill Hodson, has been appointed to the vacant post, and has begun the process of applying to the CSCI for registration. The post of deputy manager has gone out to advert. Mrs Hodson has obtained NVQ Level 3. She is now to go on to register for Level 4 and the necessary qualifications required of registered managers. Craegmoor’s services are extensively audited by the organisation. It has a ‘Clinical Governance’ team, aiming to ensure that all establishments achieve a minimum standard of performance, and then promote them to move beyond this to reach a level of excellence. The manager has to submit various weekly and monthly reports. There are also visits to the home by senior managers.
Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 22 Service users’ meetings are held once a month. Records are kept of these sessions, which are an opportunity for the home’s residents to make their views and wishes known. Relatives have also been surveyed for their feedback in the past, although this exercise has not been carried out recently. The home has a service development plan, drawn up in October 2005. This includes various targets, including service viability, staff issues, health and safety topics, and relations with external bodies. But none of the present objectives are based on service users’ views; nor do they reflect their aims and outcomes. There are also no timescales set for objectives, to enable measurement of progress. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X N/A X 2 X X X X Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 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. Standard Regulation 1 YA9 12-1 13-6 15 Requirement The persons registered must ensure that there are documented risk assessments and management strategies in place for all key needs of all service users. (Timescale of 28/06/05 not met) Timescale for action 31/01/06 1 2 YA9 YA39 17-1a Sch3-1b,3q 12-2,3 24 COMMENT: Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. This part of Regulations also 31/01/06 applies to the above Requirement. The development plan for the 31/03/06 home must reflect aims and outcomes for service users; and include timescales linked to an audit at least annually. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 25 No. 1 Refer to Standard YA1 Good Practice Recommendations The Service User Guide should be reviewed and completed, ensuring that all relevant information is included. COMMENT: This recommendation of the previous inspection was not checked on this occasion. Progress in care planning should continue, giving attention to the detail of content, and the accessibility of information. Risk assessments and management strategies should show who has been involved in devising them. Additions and amendments to pre-printed medication administration records should be signed and dated; and cross referenced to the prescribing instructions. Copies of individual guidelines on the use of ‘as required’ medication should be kept with other medication information in the main administration folder. The home should obtain further advice and training on moving and handling of service users. 2 3 4 5 6 YA6 YA9 YA20 YA20 YA35 Westbury Lodge DS0000028438.V276658.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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