Inspection on 28/06/05 for Westbury Lodge

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbury Lodge 13/11/08

Westbury Lodge 19/11/07

Westbury Lodge 24/01/07

Westbury Lodge 10/05/06

Westbury Lodge 13/12/05

Westbury Lodge 25/10/04

Westbury Lodge 20/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Westbury Lodge 130 Station Road Westbury Wiltshire BA13 4HT Lead Inspector Tim Goadby Unannounced 28th June 2005 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 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 D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westbury Lodge Address 130 Station Road Westbury Wiltshire BA13 4HT 01373 859999 01373 01373 864512 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkcare Homes (No 2) Limited Mrs Mary Docherty Care Home 9 Category(ies) of LD Learning Disability (9) registration, with number of places Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2004 Brief Description of the Service: Westbury Lodge provides care and accommodation for 9 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. The home is managed by Mrs Mary Doherty. Accommodation in the home is provided over 2 floors, with 7 bedrooms on the first floor, and 1 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 10 minutes walk from the centre of Westbury. Bus stops and a main line station are a few minutes walk away, and a small car park is available at the front of the building, with a driveway onto a busy road. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in June 2005. Since the previous inspection, in October 2004, there had been one further visit to the home, in April 2005. This took place in connection with the investigation of an incident under local adult protection procedures. The visit was by appointment, and focused specifically on the arrangements for care and support of 1 service user. Feedback from this was confirmed in writing to the home, and shared with other agencies involved. The issues identified were followed up at this inspection. On this occasion, 6.25 hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; sampling a meal; discussions with service users, staff and management. What the service does well: What has improved since the last inspection? All requirements from the previous inspection, in October 2004, were met. In addition, progress had also been made on a number of the issues highlighted at the visit of April 2005. The staffing situation was far more stable than at the last inspection. A number of new appointments had been made. Although there was still some use of relief and agency staff, this had decreased substantially. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 6 The needs of 1 service user, that had been causing particular concern for a time, were now being met more effectively. Recent reviews by relevant professionals had concluded that Westbury Lodge was doing well in supporting this individual, and that it was “very important” that the placement continued. Information about the service, in key documents, has been reviewed and expanded. The majority of the required criteria are now included. A few areas remain for attention. What they could do better: Westbury Lodge is currently registered to provide only for adults aged 18 to 65 who have a learning disability – registration category LD. This means that care can be offered to people who have been assessed, by a person qualified to do so, as having a learning disability. Mental health needs fall under a separate registration category – MD – defined as ‘mental disorder excluding learning disability and dementia’. If care is offered to people assessed, by a person qualified to do so, as suffering from a diagnosed clinical mental illness necessitating care and/or treatment, an establishment must have the relevant registration category. The home needs to address this in respect of 1 of its current service users. Associated with this, staff need training in relevant mental health topics. This should equip them to address any deficits currently arising in devising strategies to meet this person’s needs. The level of training needs to be tailored to the individual job roles. But all care staff will need some basic awareness. Evidence of assessment processes for prospective service users needs to be clearly shown. This is a live issue for the home at the moment, as there is a vacant place that they are in the process of trying to fill. Risk assessments and management strategies for all significant needs identified for service users are not yet in place. Whilst relevant referrals for advice have been made, the home needs to be more active in putting its own interim guidance in place. Otherwise, there is no evidence of awareness of needs, or of steps being taken to address them. Please contact the provider for advice of actions taken in response to this Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 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 standard(s) 1, 2, 3 & 5 Prospective service users have the necessary information to make a choice about the home. Service users have their needs met by the care provided. The service needs to review its resources and facilities, to demonstrate that it is able to effectively support all the needs of all current service users. Service users have individual terms and conditions of residence in the home. EVIDENCE: The Statement of Purpose and Service User Guide have been reviewed since the previous inspection. Other documents are also available, which set out various information about the home. Most of the relevant criteria are addressed. There should be more clarity about relevant local contact details, and the availability of inspection reports. Service users’ views of the home should also be included, where these can be obtained. The documents are displayed in the home’s entrance hall. Copies have also been placed in each service user’s records. Westbury Lodge has had 1 service user place vacant for about a year. There had been several enquiries over that period, but none had been considered Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 10 suitable, for varying reasons. An assessment had recently been carried out on a prospective new resident. The manager said that this process had been led by her area manager, as she was not familiar with Craegmoor’s new format. This assessment tool was said to cover all necessary topics. But a copy of the relevant documentation was not available in the home. The service has a well established user group. The staffing situation has also stabilised since the previous inspection, which has helped with providing a consistent approach. A range of relevant professionals are also consulted, to assist with devising strategies for individual needs. There was various input happening around the time of this inspection. For 1 service user in particular, it was clear that the individual’s mental health needs were as significant as their learning disability. This was true both in dictating the type of care and support that they needed, and in their ability to access the programme provided by Westbury Lodge. There was close involvement of professionals from both teams. The placement was felt to be meeting the person’s needs well, after a period of instability. Progress had been made on some issues identified for attention in April 2005. But the service needed to recognise the additional aspects of provision required for this individual, by ensuring that all appropriate resources were in place. An application for the relevant registration category, in respect of this person, must form part of this process. When service users are identified as ready to move on to more independent settings, steps are taken to try and find suitable placements. Sampled files showed that service users have individual contracts, and terms and conditions of residence. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 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 standard(s) 6, 7 & 9 Service users have their needs reflected in individual plans. But these would benefit from further development, to ensure that they provide more effective evidence of the support given. Service users are able to make decisions and choices about their daily lives, and future options. Service users are placed at risk of harm by a failure to have clearly recorded assessments and management strategies for key areas of need. EVIDENCE: Sampled files showed that care plans are in place, and are kept under review. Input and advice is accessed from other professionals, where relevant. Some information was not set out in sufficient detail, as a number of key elements were combined under a single heading. Each separate area of need should be described as objectively as possible. The threshold for particular interventions, such as administration of ‘as required’ medication, also needs to be more clearly defined. This will promote consistency of approach across the Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 12 staff team. It will also help in gathering information likely to be of assistance in seeking support from other professionals. For plans that have been in place for some time, it would be sensible to draw up a new front sheet when they change substantially. Otherwise, there is a risk that key differences may not stand out, amongst a number of evaluations where nothing much had changed. It may also be worth removing and archiving plans that have been discontinued. At the moment, they appear in the midst of those that are still ongoing. Examples were seen of service users exercising choice in their daily lives. Sampled files showed that individuals were participating fully in meetings about their care and future options, where they were able to do so. The team meeting that took place on the day of the inspection also included a discussion about the importance of respecting service users’ choices. Risk assessments were in place on the records sampled. But not all relevant topics had been addressed for one individual. Work was underway, but had been delayed whilst awaiting advice from other sources. The lack of any evidence of an interim approach meant that there was no recorded evidence about key current issues, or the management strategies for these. Pending further input from relevant professionals, the home must ensure that its own care record demonstrates that all reasonable steps are being taken to ensure the protection of service users. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 16 & 17 Service users have opportunities to maintain and develop skills, enabling them to work towards their desired goals. Service users are supported to access a range of activities and opportunities, and to participate as members of their local community. Service users have their dietary needs met by the home’s arrangements for the provision of meals. EVIDENCE: Service users are supported to maintain and develop skills wherever possible. In particular, accommodation for 1 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. 1 service user was out attending a day service facility when this inspection took place. The others were all at home. The college that a number of people Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 14 attend for various sessions had just closed for the summer. So residents were going to be more reliant on Westbury Lodge’s own staff to provide activities during the holiday period. A number of day trips had taken place, and more were being planned, based around the known preferences of the user group. The home has its own vehicle, although only 1 current staff member is able to drive this. 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 was being accessed to try and help people work through these difficulties. Activities are usually led by a co-ordinator. But this person had been absent for some time, due to maternity leave. It was not yet clear when they would return. In their absence, the remainder of the staff team were trying to offer as much engagement and stimulus as possible. Various activities were observed taking place at the home. A service user with a visual impairment had a book read to them. Another was doing some knitting. A third person was supported to do painting. Outside the home, there is regular use of various local amenities, such as shops and pubs. Information about service users included clear details about any issues in forming relationships with them. The importance of taking care to establish an effective rapport was well set out. 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. Menus were available, and showed that a variety of food is offered. They were just about to be changed to a summer version. The majority of service users have no specific dietary needs. One person has to have all food liquidised. The dietitian has given input, to ensure that the individual’s needs are being met appropriately. Service users can access the kitchen, with supervision. Some are able to make drinks and snacks independently. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 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 standard(s) 18 Service users’ personal care needs are met in line with their preferences. EVIDENCE: The personal care needs of service users were discussed in the team meeting that took place on the day of this inspection. All individual plans contain relevant guidance on people’s needs and preferences in this area. There is also a recognition of the right of service users to decline assistance. The approach stressed for staff is to offer encouragement and support, but never to impose themselves. It is seen as important to maintain those skills that people do have, so they can be as independent as possible. 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. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 16 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 standard(s) 22 & 23 Service users’ welfare and safety are protected by the procedures operated by the home. EVIDENCE: Craegmoor has a complaints procedure, which is prominently displayed in the home. Records are kept of any concerns raised, and of the actions taken in response. There had been 1 complaint received shortly before this inspection. The manager provided details of the response to this, which was considered to be appropriate. There are also policies relating to abuse and adult protection. The home is aware of the local multi-agency procedures in this area. Where appropriate, issues have been referred for consideration under these. There had been 3 such referrals since the previous inspection. 2 of them remained ongoing at the time of this visit. Relevant actions had been taken, in line with the decisions of the various meetings that had been held. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 17 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 standard(s) 24, 27 & 30 Service users live in a comfortable, safe and clean environment, suitable to their needs. EVIDENCE: Not all areas of the home were seen during this inspection. Those that were visited were clean and well maintained. Issues identified for attention at the previous inspection had been addressed. The home employs its own handyman, who can attend to a variety of jobs as the need arises. External contractors are engaged where appropriate. 2 service users have en-suite showers. One of these had recently been replaced. The other residents have general use of 2 bathrooms, both on the first floor. All bedrooms have handbasins. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 35 Suitable numbers of staff are provided to meet the needs of service users. Staff have not received training in all relevant topics for the support of the current service user group, placing some of those users at risk. EVIDENCE: Rotas provide for at least 3 staff to be on duty for daytime shifts. Night-time cover consists of 2 waking staff. There is a separate team of night staff. The minimum number of staff present in the home is usually 2, because of the needs of some service users. 3 staff were on duty on the morning of this unannounced inspection, in addition to the manager. There were also 3 staff on the afternoon shift. A team meeting took place during the handover period. The staffing situation had stabilised since the previous inspection, with a number of new appointments. The home was making much less use of agency staff. Craegmoor also has a pool of relief workers, who can help to maintain cover. 2 staff had achieved NVQ awards at Level 3, and 3 others had done so at Level 2. The home was just achieving the 50 target in this area. It was hoped to Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 19 make further progress soon. Another 2 staff were working towards this qualification, and others were due to start it in the near future. One of the home’s senior support workers acts as training co-ordinator. Records are maintained, showing what courses each staff member has undertaken. The need for training in mental health topics had been identified, and the community psychiatric nurse had agreed in principle to provide this. But no specific sessions had yet been scheduled. The significant mental health needs of 1 service user mean that this is a key issue for the home. All staff should receive sufficient instruction to promote a basic awareness of the individual’s mental state, and the likely impact on their behaviour. In addition, some designated staff would need to develop greater expertise, to enable them to work effectively with other professionals in assessing, planning and reviewing the person’s care. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 42 Service users’ health and safety are protected by the systems in place. EVIDENCE: The home’s registered manager is Mrs Mary Doherty. She is currently working towards the NVQ Level 4 qualification which all such managers are required to complete by the end of 2005. She reported that she anticipates finishing it in October. Evidence is available to show that a range of health and safety checks are carried out. This includes both internal monitoring, and programmed visits from relevant contractors. Fridge temperatures were being recorded daily, and showed that the appliance was operating consistently at 8°C. This is at the upper limit of the recommended safe range, and it would be preferable to aim to maintain the usual temperature at 5°C. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 21 The fire log book provided evidence that the range of required safety checks are carried out and recorded at the prescribed intervals. Practices and staff instruction had been fulfilled in the first quarter of the year, but not yet for the second, which was just about to finish. Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 2 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbury Lodge Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 23 No 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 YA2 Regulation 14(1); 17(1)(a), Schedule 3(1)(a) Reg 12, National Care Standards Commission (Registration) Regulations 2001 (as amended) 12(1); 13(6); 15; 17(1)(a), Schedule 3(1)(b) & (3)(q) 18(1)(a) & (c) Requirement The persons registered must provide evidence that the needs assessment for prospective service users covers all required criteria. The persons registered must ensure that registration categories accurately reflect the service user group provided for. Timescale for action Not later than 31/08/05. Application to be received by the CSCI not later than 31/08/05. 2. YA3 3. YA9 The persons registered must ensure that there are documented risk assessments and management strategies in place for all key needs of all service users. The persons registered must ensure that staff receive suitable training to enable them to provide effective support to service users with significant mental health needs. From 28/06/05. 4. YA35 Action plan, with suitable timescales, to be provided not later Page 24 Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 than 31/08/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA6 Good Practice Recommendations The Service User Guide should be reviewed and completed, ensuring that all relevant information is included. Progress in care planning should continue, giving attention to setting out each key element in sufficient detail; and ensuring that review processes aid easy identification of current information. More care staff should commence studying for NVQ awards as soon as possible. All fire instruction and practices should be carried out and recorded at the prescribed frequencies. Care should be taken to maintain the fridge temperature at the recommended safe level. 3. 4. 5. YA32 YA42 YA42 Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westbury Lodge D51_D01_S28438_WESTBURYLODGE_v233252_150605_Stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!