CARE HOME ADULTS 18-65
Westbury Lodge 130 Station Road Westbury Wiltshire BA13 4HT Lead Inspector
Tim Goadby Unannounced Inspection 19th & 22nd November 2007 09:25 Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 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 Ltd 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) Mrs Clare Louise West 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.V354477.R01.S.doc Version 5.2 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. 26th January 2007 Date of last inspection Brief Description of the Service: Westbury Lodge provides care and accommodation for up to nine adults who have a learning disability. One person using the service has associated mental health needs. Some others also have sensory impairments. The home is owned by Parkcare Homes Ltd, a division of Craegmoor Healthcare, who operate a group of homes locally and across the country. Accommodation in the home is on two floors, with seven bedrooms on the first floor, and one bedroom and a semi-independent flat downstairs. All persons accommodated on the first floor must be able to climb stairs without assistance, as there is no lift. The flat has a shower room, and the other ground floor bedroom has an ensuite shower. There are two bathrooms for general use upstairs, both of which also have showers. The ground floor also has a sitting room, dining room, kitchen, and laundry. There is a secluded and secure garden. The home is on the edge of a residential area, about ten minutes walk from the centre of Westbury. Bus stops and a main line rail station are a few minutes walk away. A small car park is available at the front of the building, with a driveway on to a busy road. Information for people using the service is displayed in the home, including some in picture formats. Key issues are discussed individually, or within residents’ meetings. CSCI inspection reports are included in these discussions when they are received, and a copy is always available in the home. Fees charged for care vary, depending on the assessed needs of individuals. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was completed in November 2007. The process included a review of information received about the home since its last main inspection, which was in January 2007. This included various incidents which the home has notified us about; a shorter follow-up inspection which we conducted in July 2007; and the registration of a new manager in October 2007. For this key inspection we asked the home to complete an Annual Quality Assurance Assessment (the AQAA). This document contains key information about the service, as well as their own judgements and evidence about how well they are doing in all areas of service delivery. We made two visits to the home. The first of these was unannounced, lasting just over four hours in total. The pharmacist inspector attended for part of this visit. A second visit took place by appointment later in the same week, to meet with the registered manager, conclude the inspection and give feedback. The fieldwork at the visits included sampling records, discussions with people using the service and staff on duty and a tour of the home. The pharmacist inspector looked at arrangements for the handling of medicines. The judgements in this report are based on all the above sources of evidence. What the service does well:
People using the service are supported to address their health care needs effectively. They have various physical and mental health needs which are set out in their individual plans. There are systems to monitor and record key indicators. Other professionals are involved in reviewing and evaluating care. People using the service have a range of regular health checks. People using the service can maintain appropriate relationships with their family and friends. The home offers support both by enabling visits and calls to Westbury Lodge, and by escorting its residents to visit people elsewhere. People living at the home are protected by the procedures for responding to complaints and concerns. Craegmoor has suitable internal systems for investigating these. There are appropriate staff conduct and discipline procedures. The service has also linked to local multi-agency procedures for safeguarding vulnerable adults if this has been necessary in the past. Staff receive a range of relevant training, from induction onwards. Craegmoor has organisational systems to support this. People living in the service benefit from the support of staff who have relevant knowledge and skills.
Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 6 People using the service are protected by recruitment procedures. All new staff have all required checks carried out before they begin work at the home. What has improved since the last inspection? What they could do better:
Support with medication needs some improvements to ensure that all people using the service are protected. All medicines which are not used often must have clear guidelines for use and be regularly reviewed with the prescriber. Risk assessments and procedures must be in place for any medication given to residents to self-administer. The home also needs a suitable cupboard for possible storage of controlled drugs, following recent changes in legislation. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 7 The current programme of repairs and redecoration to parts of the property needs to continue, so that all parts of the home are clean, safe and comfortable. In particular, the planned replacement of the lounge carpet and the repair of damaged kitchen units are still needed to fully address a requirement of the home’s last inspection. Systems for quality assurance need to develop so that they have a clearer link to the expressed wishes of people using the service and their supporters. Staff knowledge and skills could develop further in particular topics, such as alternative methods of communication with some of the people using the service. This will help staff to provide more effective support. The service should continue with work on developing the range of activities and opportunities which are available to all the people living at the home. The planned weekly programme for each individual is not yet delivered reliably. 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 Lodge DS0000028438.V354477.R01.S.doc Version 5.2 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.V354477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service have their needs assessed and are able to make an informed choice about the home. EVIDENCE: There have been no new admissions to Westbury Lodge since August 2005. The service has had two vacant places for the past year. One person is now likely to move into the home. We saw evidence of thorough preparation and a suitable decision making process for this. The home has obtained full assessment and history information about the new person. The individual has had the chance to visit Westbury Lodge on a number of occasions, including for overnight stays. All the staff and current residents of the home have been given relevant information and a chance to meet the prospective new person. There are plans for ongoing support to the individual and the home from relevant professionals once the person moves in. The likely new admission was visiting Westbury Lodge on the second day of this inspection. They appeared to be enjoying their stay and seemed at home Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 10 in the surroundings. They told us they have chosen their bedroom and colour scheme. They were looking forward to moving in and also starting college. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service have their abilities, needs and goals reflected in their individual plans. People using the service can make choices and decisions in their daily lives. EVIDENCE: Craegmoor has implemented ‘person centred planning’, with all its services adopting a new format. This involves the people using services as much as possible. At Westbury Lodge, where some are less able to contribute, information has been gathered from families and the staff team as well. Three sets of records were checked. All were well ordered and contained a range of relevant information. Each person’s folder has sections including life history, relationships, support plans, weekly activities and risk assessments. Some of the written information is supported with pictures and photos to make it more personal and accessible.
Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 12 One person who is more able has contributed directly to their own file by making their own written entries. The records show evidence of regular review. Where new needs have arisen, steps have been taken as a result. There are suitable strategies in place to help minimise identified risks. This includes an effective response to issues of concern, such as those arising from behaviour or mental state. The home has involved relevant specialists, including a consultant psychiatrist and members of the local community team for people with learning disability. People living at Westbury Lodge have widely varying needs and abilities. This influences how independent they are in choice and decision making. One person does lots of things without staff support, both at home and outside. The others need greater support, at different levels. Care plans contain information about this. Staff work to promote choices and decisions for all people using the service. Those individuals who understand spoken language are given various options to choose from, by asking them what they would like. The home is also looking into other methods, which will suit non-verbal service users. These include getting information about various systems which use signs, symbols or pictures to aid communication. Staff training is planned in these. One person living at the home was supported to choose new decoration and furnishings for their own room by using photos from catalogues. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with a range of activities and opportunities. They would benefit from further developments in this area. People using the service are able to maintain and develop appropriate relationships with family and friends. People using the service have their rights and responsibilities upheld, balanced with appropriate steps to safeguard their welfare. People using the service are offered a variety of meals, in line with individual needs and preferences. EVIDENCE: Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 14 Some people living at Westbury Lodge attend college courses or other day service facilities for part of the week. One also has part-time employment. More people are starting college courses in January 2008. Most people using the service rely on support in activities, both at home and in the community, from Westbury Lodge’s own staff. Some people have proved more difficult to engage in activities outside the home. This may be linked to mental state, anxieties or phobias. Work has been undertaken to try and address these issues. Individual participation in the local community varies depending on people’s abilities and behaviours, and the confidence of the staff team to support these. Access may also be limited because not all the home’s staff are able to drive. However, progress has been made in both these areas. Over the two days of this inspection visit most of the home’s residents were going out for sessions including college, shopping and lunch. Some people regularly attend clubs. Some have been swimming occasionally. Each person living at the home has allocated one-to-one time with a staff keyworker and these sessions are often used to take them on outings. In the home, people undertake various activities in line with their own interests. Examples include knitting, jigsaws, foot massage, art and ball games. A first floor room has been fitted with sensory equipment and the plan is to buy more. Occasionally entertainment such as music or magic is provided by people visiting the home. The service still aims to develop its provision of activities and opportunities for people living at the home. A full weekly timetable is drawn up for each person and displayed on a whiteboard in the dining room, but during our visits not all of these sessions were being kept to. This indicates the need to review the current approach. There is information in people’s care plans about their key relationships, and how these contacts are maintained. Most have regular arrangements for keeping in touch with relatives, through visits, letters and phone calls. 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. Menus are drawn up over a six week period. The majority of people using the service have no specific dietary needs. One person has to have all food liquidised. A dietician has given input, to ensure that the individual’s needs are being met appropriately. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 15 People living in the home can access the kitchen, with supervision. Some take part in meal preparation, or in clearing away afterwards. Some are also able to make drinks and snacks independently. Staff give support to anyone who needs assistance during mealtimes. A dietician visited in February 2007 to discuss the home’s menus and offer advice. Various recommendations were made which have been incorporated into the home’s practice, to promote healthier eating. Some staff had raised concern that weekly budgets for food were not sufficient. These are due to be increased from the beginning of 2008. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are supported to address their personal and health care needs effectively. The procedure for the administration and recording of medicines protects residents in the home. However this must be extended to cover the occasions when they are away from home. EVIDENCE: People living at Westbury Lodge have varying abilities and needs in relation to personal care. Some are largely independent. Others need different levels of support. These issues are set out in their care plans. People also have a variety of physical and mental health needs. These are also covered 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
Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 17 home, including reviews of medication. Mental health professionals are involved closely for those people who need this. Sampled records show that people using the service receive regular health checks. This includes input from dentists, opticians, and a chiropodist. Medication is stored securely. However the controlled drugs cupboard does not meet current legislation. The home is considering changing where medication is stored and will be able to install a suitable cupboard as part of this. A new system had been introduced on the day of the inspection whereby one member of staff is responsible for all the medication during their shift and has control of the keys. Medication administration records were clear. Changes to medicines or doses were confirmed by notes attached to the file and signed by all staff before they administered the medicines. Protocols were available for two medicines prescribed ‘as required’ and the doses and quantities given were clearly recorded. One medicine prescribed in this way had not been used for some time and there were no guidelines available for its use. All medication is recorded when received into the home or returned to the pharmacy. Although no residents currently have responsibility for their own medicines a single dose may be given to some residents to take when they are away from the home. This process must be risk assessed and a procedure for issuing the medicines drawn up. All medicines were in stock, and a local procedure and information about them were available to staff. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: Craegmoor has a complaints procedure, which is prominently displayed in the home. Records are kept of any concerns, and of the actions taken in response. Records show that concerns may originate from people living at the home, their relatives, or staff. All recent issues have been dealt with appropriately. There are also policies relating to abuse and adult protection. The home is aware of the local multi-agency procedures in this area. Various issues have been referred to this when necessary. Guidelines for the management of behaviour have been developed so that they give clearer guidance about the actions staff must take, and the reasons for the chosen approach. All the files we sampled had relevant information about any behavioural and mental health needs of people using the service. Some use of physical interventions is possible with some service users. Staff receive relevant training. Guidelines make clear that physical interventions are a final step. They also set the limits of which techniques staff may carry out. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is adequate but improving. This judgement has been made using available evidence including a visit to this service. People using the service mostly live in a comfortable, clean and safe environment, suitable to their needs. Attention is needed to some outstanding areas of work. EVIDENCE: The main lounge on the ground floor is being redecorated. It has been painted and a broken radiator cover has been repaired. Some new furniture has also been purchased. The carpet is worn and heavily discoloured in several places. It is due to be replaced soon. Most of the damage caused by a leak in a first floor bathroom in March 2007 has been repaired. The affected room, with a bath, shower and toilet, is now back in use. The kitchen is below where the leak occurred. The damaged area of ceiling has been repaired. Walls need repainting, because of marks which have run
Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 20 down from when the ceiling was re-plastered. Damaged kitchen units have not yet been replaced. Heating for the en-suite shower room in the ground floor flat was installed in July 2007, addressing a requirement of the previous main inspection. Maintenance and décor is generally good, with an ongoing programme to address necessary tasks. The home employs its own handyman, who can attend to a variety of jobs as the need arises. A new person has recently been appointed to this role and is completing various repairs and redecoration. External contractors are engaged where appropriate. Craegmoor has a list of preferred providers which it normally uses. Following an outbreak earlier in 2007 the home has reviewed its systems for infection control. A copy of the most recent guidance for care homes on this topic is available. Cleaning schedules and staff hygiene practices have been reviewed, and good practice messages reinforced to the team. The home has also obtained a new washing machine, which has a sluicing cycle. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported by suitable numbers of appropriately trained staff. People using the service are protected by effective recruitment practices. EVIDENCE: The staff team for daytime cover includes a manager, deputy, senior support worker and support workers, some of whom are part-time. With seven people living at the home, there are at least two staff on each daytime shift. Rotas aim to have more than this whenever possible. Numbers will adjust as and when people are admitted to the two vacant places. On weekdays, the home manager and deputy are usually both on duty during daytime hours, along with two to three other staff working early or late shifts. Nights are covered by two waking staff. There are three night staff who cover the majority of these shifts, with other members of the team from days doing
Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 22 occasional nights to provide necessary cover. Rotas show that the practice of some night staff working long unbroken runs of shifts has ended, with five or six consecutive nights being the most planned for any employee. The manager, deputy or senior support worker provide on-call cover when none of them are on duty at the home. Records show that all staff receive mandatory training in topics such as first aid, food hygiene and health and safety. Courses are also provided on issues such as abuse prevention, physical interventions and medication. Craegmoor has an organisational approach to induction and foundation training. This links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with learning disability. Successful completion of this package provides workers with a pathway into National Vocational Qualifications (NVQs). Craegmoor also has its own NVQ centre, so it can drive this training for its own employees. Following recent staff turnover, Westbury Lodge is slightly below the 50 target for care staff with NVQ Level 2 or higher. Two staff have Level 3 and another four have Level 2. Not all of these are full-time staff. Three staff are studying for the Level 2 award. Once they complete this, the home should once again be above the 50 threshold. Two sets of staff records were checked for people recently appointed to the home. These show that all required recruitment checks are carried out. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good overall, although quality assurance is only adequate. This judgement has been made using available evidence including a visit to this service. People living in the service benefit from a well run home. More evidence is needed to show that their views underpin service planning and development. People living in the service have their welfare protected by systems for upholding health and safety. EVIDENCE: The home’s manager is Mrs Clare West. She took up the post in January 2007 and completed the process of registration in October 2007. Mrs West previously worked as deputy manager in another local Craegmoor home. She has completed her National Vocational Qualification in management at Level 4 Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 24 and is now undertaking the Registered Managers Award. She expects to complete this in Spring 2008. Craegmoor has various systems for auditing its services. There is 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. The service has an Overview Audit which sets out targets for improvement and development, with the actions to be taken towards these. The document is reviewed and updated monthly. Craegmoor’s area manager visits the service at least once a month. These visits include carrying out a check and report on the conduct of the home as required in Care Homes Regulations. Current service development targets include improvements in communication with service users and to the premises. All people living in the service have allocated staff keyworkers, who can be their main point of reference for raising any issues they have. They also have weekly meetings. Staff are involved and consulted about the running of the service. They have meetings every fortnight. They can also contribute comments and raise questions at any time, and receive an appropriate response. Systems have been put in place to help with the routine daily running of the home. Staff commented that they feel these have been beneficial. The service has not yet devised formal systems for consultation with people living at the home or their families, so their views are not directly linked to the current audits and improvement plans. There are designated staff members who are health and safety leads. A health and safety committee meets regularly, to identify any areas for attention and to follow these up. A range of health and safety checks are carried out. This includes both internal monitoring, and programmed visits from relevant contractors. Full audits of the premises are carried out every six months. Risk assessments are in place for a range of safe working topics. The fire log book shows that all required checks relating to fire safety are carried out at the prescribed intervals. Records of staff instruction are also up Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 25 to date. The property has a fire risk assessment, and actions identified in this have been followed up. Problems with the home’s gas supply shortly before this inspection have now been resolved. The source of a leak was made safe, and pipework has been re-sited to reduce future risk. Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 3 X Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation 13-2 Requirement All medicines which are not used often must have clear guidelines for use and be regularly reviewed with the prescriber. Risk assessments and procedures must be in place for any medication given to residents to self-administer. All controlled drugs must be stored in a cupboard that meets the current storage regulations: The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007. The persons registered must ensure that all parts of the lounge and kitchen are kept in a good state of repair and reasonably decorated, for the safety, welfare and comfort of service users. (Timescale of 30/09/07 partly met) Systems for quality assurance and service development must include the views of people using the service.
DS0000028438.V354477.R01.S.doc Timescale for action 31/12/07 2 YA20 13-2 25/01/08 3 YA20 13-2 31/03/08 4 YA24 23-2b,d 31/01/08 5 YA39 24-5 31/03/08 Westbury Lodge Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations Steps should be taken to develop the knowledge and skills of staff in various methods of communication, to help them meet the needs and preferences of all the people living in the home. The home should continue to develop the range and frequency of activities and opportunities offered to all the people living there. The programme of redecoration and improvements to the home should continue, so that people living there benefit from a more comfortable environment. The home should continue with planned steps for NVQ training to try and ensure that it remains above the 50 target for care staff with Level 2 or above. 2 YA13 3 YA24 4 YA32 Westbury Lodge DS0000028438.V354477.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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