Inspection on 02/03/07 for Westcombe Park Nursing Home

This inspection was carried out on 2nd March 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westcombe Park Nursing Home 03/02/06

Westcombe Park Nursing Home 26/07/05

Westcombe Park Nursing Home 20/04/05

Westcombe Park Nursing Home 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Westcombe Park Nursing Home 112 Westcombe Park Rd Blackheath London SE3 7RZ Lead Inspector Keith Izzard Unannounced Inspection 2nd March 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westcombe Park Nursing Home Address 112 Westcombe Park Rd Blackheath London SE3 7RZ 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) 020 8293 9093 020 8858 2026 hillsn@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Nicola Hills Care Home 51 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (51) of places Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 10 beds for general nursing care of people aged 50 41 beds for the general nursing care of people aged 60 As agreed on the 25/05/2006, one named Service user (female), with dementia, can be accommodated within the home. 3rd February 2006 Date of last inspection Brief Description of the Service: Westcombe Park Nursing Home is located to the rear of a privately owned apartment block, which is managed by Goldsborough Estates. The home is sited on a residential road within walking distance of local shops and public transport links at Blackheath Standard. Access to the front entrance of the Care Home is restricted to ambulances or vehicles collecting or dropping off visitors or service users. Parking is provided for visitors in front of the private apartments. Westcombe Park Nursing Home is registered to provide nursing care for 51 male or female service users, ten of whom can be aged 50 years and over and 41 of whom must be at least 60 years of age. Accommodation is provided on three floors. Each of the floors has a variety of bedrooms, fortythree of the rooms are single occupancy and three rooms are shared. Forty of the bedrooms have en-suite facilities. The fees payable for residents range between; £550.00 - £ 1071.00 per week. Each of the floors has a communal lounge, bathrooms and toilets. On the ground floor there is a dining room and a large lounge, which is used for activities. Kitchen and laundry facilities are provided on site. At the rear of the property service users have access to a shared garden. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 9.15 –3.30 and was conducted by two Inspectors. The Manager and Deputy Manager were available throughout and assisted the inspection in a positive and constructive way. The Inspectors were able to talk freely with staff and residents, viewed the premises, and examined care plans, medication, maintenance records and other documentation. The Inspectors talked with eight residents and the Deputy Manager assisted one Inspector in talking to one resident who had communication difficulties. In all, five care staff were interviewed, and two nurses and also the deputy chef, the laundry manager a domestic staff member and both maintenance men. In general, care staff members were observed to be seen carrying out their duties in a caring and professional manner. Apart from odour in one area of one unit the home was clean throughout, and generally well maintained. There is an ongoing programme of redecoration, and where possible, service users are able to choose their preferred décor for their bedrooms. All residents spoken to were cheerful and talked positively about the home, the Manager, the staff, the food, and the activities provided. They were well groomed, and encouraged to sit where they wished, and to get up/ go to bed according to choice. What the service does well: Residents clearly enjoy living in the home, and are treated with respect and dignity by the staff. They are able to go out with assistance from staff, and a staff member will fetch any shopping they require. They are able to join in with activities if they wish, or stay in their own rooms, or sit in one of the quiet areas. Visitors are welcomed at any time. Activities and outings organised were well organised and appreciated by service users. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 6 The home facilitates care staff in carrying out NVQ training, and 15 out of a total of 26 had completed NVQ level 2 or 3. This is above the projected percentage in the National Minimum Standards, and the home is commended for this. Maintenance records were clearly recorded and easy to follow, and the home employs 2 maintenance men to ensure that facilities are kept to a high standard. What has improved since the last inspection? What they could do better: Only two requirements were made; one to ensure that there is always a staff member available to answer a call bell as one incident of delay was observed during the inspection. The other to ensure bad odours would be dealt with as soon as practicable as this was noted in one area of the home at the inspection. Only two recommendations were made; one that increased efforts should be made to assist one female service user to be attired in a more dignified manner. It was evident that this person was not always co operative in this regard and had resisted staff attempts to assist her, nevertheless for her own dignity staff members should continue to persevere with their attempts to assist her in this respect. The other, was to ensure that the bathroom, currently out of action, be repaired as soon as practicable. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 7 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. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are made to ensure that the home can meet the needs of the residents. EVIDENCE: Standard 3 The Inspector viewed two pre-admission assessments, and noted that these were carried out using a pre-printed format, were suitably detailed and usually carried out by the Deputy Manager, who is a trained nurse, and the home’s Head of Care. Information was comprehensive and included residents’ personal data; medication; medical history; activities of daily living (e.g. mobility, communication needs, continence, sleep pattern, personal hygiene needs); mental state, skin integrity and personal safety issues. Other information included a history of falls, and social and family interests. A placement is only Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 10 offered if the home is able to meet the assessed needs of the resident. The Deputy Manager of the home, had consulted CSCI on several occasions, when any doubt has arisen regarding the appropriateness of a potential admission in respect of the homes registration category, this is good practice. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain detailed information that enables staff to give effective care. Health needs are well met; and medication administration is generally satisfactory. Residents feel that they are treated with dignity and respect. EVIDENCE: Standard 7 Two sets of care plans and associated daily notes were seen on both the first floor and ground floor units and three on the top floor unit. All included plans for eating, drinking and sleeping. These were reviewed monthly and files Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 12 contained a completed life map that listed the hobbies and interests of the residents. One also stated that the resident “prefers own company”, and staff corroborated this. All had weight charts and these were completed on a monthly basis also except for one service user where this was no longer possible owing to her medical condition, this was clearly stated on the care plan. The manager said that all care plans are to be rewritten and residents reassessed on a ‘clean sheet’ as new records were being introduced by BUPA. Standard 8 Consent for the use of cot sides was seen on one file, and the relative of the resident had signed this. One resident was seen with bruising on her arms. This had been recorded in photographs on her file, and the G.P. had been consulted on her skin viability owing to her susceptibility to bruising, and had recommended a double-based cream. Staff members had also been given specific advice for this resident in respect of manual handling by a senior staff member at the home, in order to minimise the risk of accidental bruising. Standard 9. The Inspector examined medication management on the ground floor and top floor units. Each floor has the same system in place. The medication trolley is locked in a cupboard adjacent to the nurses’ station, and storage cupboards are inside the same area. The home uses the nomad cassette system of administration. The trolleys were in good order, and medication charts had been completed satisfactorily. Two requirements and a recommendation made at the previous inspection had been complied with. These were to ensure that homely remedies do not go out of date, that no prescribed medicines go out of stock and handwritten entries on MAR sheets are signed by two staff. A list of homely remedies had been signed by the GP. Standard 10 All the residents seen were clean and well presented, and feedback from residents and visitors was the laundry was well managed. One lady had her dress open to the waist, and staff said that she preferred to be lightly attired. This was recorded on her long-term care plan, but staff must find a way to ensure the resident’s dignity is preserved in these circumstances. See Recommendation 1 Overall, eight residents spoken to by the Inspectors spoke highly of the level of care they are given, and it was evident that they are treated with respect and consideration by all levels of staff. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with a range of activities, and are assisted in maintaining their preferred lifestyles. The home caters for differing nutritional needs, and supplies a good choice of menus, and home-cooked cakes and dishes. EVIDENCE: Standard 12 The Activities co-ordinator was off sick on the day of the inspection, but information on activities within the home was gleaned from the newsletter, the week’s activity sheet and from speaking with residents. A copy of the activities plan is given to all residents. It includes skittles, ball games, and special events such as ‘Loud Tie Day’, and evening cocktail party and an Easter tea. Many of the residents prefer to stay in their rooms, and several were seen reading or watching television. One resident had asked for a television that could receive Ceefax and Teletext, and said, with some surprise, “I got what I Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 14 asked for”. The lounge on the first floor had a television and a music centre with range of CDs including Dance Band Days, Tony Bennett and Top Ten Hits of the 60s. The first floor has a small area at the end of the corridor decorated in the style of an old-fashioned pub. It is called the ‘Reminisce Inn’ and has a number of artefacts that may be familiar to residents, such as bottles, an old radio; pump handles and a painted mural of a pub scene. This is used on specific occasions. There were no newspapers or magazines in the lounge but staff said that the residents usually buy their own papers, and members of staff occasionally bring in magazines. There is a delightful enclosed garden with shrubs and a pond, and staff said that residents could go out whenever they like. One resident said that this was not necessarily the case as, “They’ll never take a few wheelchairs”. Photographs on display on the ground floor show residents on a trip out last year. This year the trips proposed include a boat trip on the Thames and a trip to Southend on sea. Standard 13 Visitors are able to visit at any time, and some visitors were seen on the day of the inspection. Two visitors were spoken to on one floor. One visitor comes every day and helps to give her mother lunch. She said that what impressed her most was the cleanliness of the home, and especially the kitchen. She said that the manager and staff are friendly and approachable. An e-mail with temporary contact numbers for a relative was placed prominently at the front of the resident’s file. Standard 14 Bedrooms seen had evidence of personal possessions, including pieces of furniture where they could be accommodated. Many had photographs of family members. Standard 15 The Residents’ Newsletter states that all menus are nutritionally assessed to ensure they meet the residents’ requirements in line with dietary research. Residents’ comments on the food included, “The food is 100 - absolutely no complaints whatsoever”, and “the food is very good – anything I’ve asked for, I’ve been given”. One resident said that supper was soup or sandwiches but added, “you can ask for an omelette”. The recently introduced ‘Nite Bite Menu’ sets out what is available after the kitchen has closed. This offers a range of snacks from beans on toast, to yogurts, cereals or chopped fresh fruit. A threecourse meal was available at lunchtime starting with soup. The main course was herb crust fish, chips and peas or quiche. Staff quickly transferred food from the trolley onto trays, with cutlery, napkins, squash and ketchup. The staff member knew what each resident liked, even down to whether they liked their tomato ketchup on a saucer or sprinkled on their meal. Plates were Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 15 covered with a plate cover, and taken to each resident. The staff member taking one meal was heard to say, “Enjoy your meal”. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a straightforward complaints procedure, and residents and relatives know that their views will be taken into consideration. Staff members are trained to recognise and prevent different types of abuse to older people. EVIDENCE: Standard 16 Complaints are audited in a complaints log every month, and this showed that four complaints had been made since the previous inspection, three were substantiated and one partially substantiated. All had been properly investigated, and action had been taken to remedy the situation. The Manager speaks to most service users each day, so that she is quickly aware if they have any concerns; and she is nearly always available to speak with any relatives or visitors during the day. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 17 Standard 18 Staff members are aware of the need to divulge any incidents of bad practice or suspicions of abuse, and are conversant with whistle-blowing procedures. Seven staff had received updated training in adult protection since the previous inspection and a further four sessions were scheduled for other staff during 2007. One alleged adult protection incident was investigated since the previous inspection; this was an alleged incident of rough handling by a member of care staff. The incident was appropriately notified to both CSCI and the local authority adult protection service and was not substantiated. The Inspector was satisfied that the allegation had been thoroughly investigated and the home had implemented procedures correctly. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment for residents and, overall, is pleasant and well maintained. There are sufficient toilets and bathrooms, and suitable specialist equipment. Heating, lighting and laundry facilities are all satisfactory. EVIDENCE: Standard 19 The Inspectors conducted a tour of the whole building. The home has a large comfortable lounge on the ground floor, a separate dining room, and quiet areas on each floor. These were well decorated, and had good quality furniture and furnishings. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 19 The kitchen area was inspected and it was noted that food was stored appropriately and regular temperature checks made in respect of fridges and freezers and the temperature of cooked food. Fly screens were in place and cooker hoods clean and subject to regular maintenance. It was noted that one bathroom was out of action, but this was scheduled for imminent repair and staff members were able to use a facility on another floor, however, this was inconvenient to both residents and staff members and it is recommended, therefore, that the bathroom is repaired as soon as possible to minimise this. See Recommendation 2 Overall, there is a thorough maintenance programme in place and the home is fortunate in having two staff members (handymen) who actively address these areas. Standard 22 During the inspection one resident pressed the call bell, and was becoming anxious when it was not answered. Staff appeared to be going past her door without registering her need. This was eventually brought to the attention of a staff member, and help was given. It appears that there are only two bleeps on this floor as one has gone to be repaired. One was with a staff member who was busy with a resident in the shower, and the second was with a staff member on a break downstairs. This is unacceptable, and staff must ensure that there is always a staff member available to answer a call bell. See Requirement 1 Standard 26 One visitor commented on the cleanliness of the home, and indeed, the rooms and corridors appeared to be clean and well maintained. However, there was an odour present in one area on the first floor corridor. See Requirement 2 The laundry was tidy and well managed. Designated laundry staff members are employed to do the laundry, so that care staff can concentrate on caring. There are 3 washing machines and 2 dryers. The washing machines have an automated system to ensure the right mix of washing powder/liquids for each wash. A red alginate bag system is used for soiled items. Service users’ clothes are usually labelled prior to admission, but when labels need replacing the laundry staff or key-workers ensure this is done. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are maintained to meet the dependency levels of residents. The company ensure that new staff have a detailed induction, and encourage all staff in completing ongoing training. EVIDENCE: Standard 27 On the first floor it was observed that there were four members of staff, one nurse and three care assistants. This appears to be in line with the staffing notice requirement for the home. Staffing rotas were examined for a period of a month that showed that the home was maintaining the required level of staffing at all times. Staffing levels have been set for each floor, according to the number of residents accommodated and their anticipated dependency levels. Additional staff would be brought on duty if dependency levels became higher – e.g. due to serious illness, requiring additional attention. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 21 The ratio of day care staff is usually 1 nurse and 2 care staff on the ground floor; 1 nurse and 3 care staff on the first floor; and 1 nurse and 3 care staff on the second floor. Care staff members are assisted in their duties by ancillary staff comprising a cook and 2 kitchen staff; a laundry assistant; two maintenance persons; and 1 domestic assistant for each floor. Night staffing consists of 2 nurses and 3 care staff for the whole building. The home employs it’s own bank staff, and occasionally uses agency staff to cover for sickness or holidays. Where possible, the same agency staff members cover shifts, as they already know the home and the service users. Nursing and care staff are enabled to carry out training to keep their professional standards up to date, and to develop their skills and competencies. Standard 28 New staff members carry out a 6-week induction programme, with the first 3 days as supernumerary. Untrained care staff work through foundational standards for 6 months, with the assistance of a senior staff member to mentor them. Care staff members are encouraged to study for NVQ 2 and 3, and at the time of the inspection, 15 out of a total of 26 care staff had completed NVQ 2 or 3. This is a ratio of 57 and the home is commended for having above 50 trained to this level. Standard 29 Staff records were looked at for four members of staff. Files were well ordered and included current criminal records bureau check, two references, proof of identity, health declaration, job description and evidence of qualifications where they existed. One new file had a helpful checklist at the front to show quickly any documents that might be outstanding. In this file too, references had been verified, which is good practice. (4) Standard 30 Ample evidence was provided of training provided for staff members from the training matrix provided by the manager. Four staff members who were interviewed, confirmed that they had received a high level of training and one who had just completed her NVQ level 2 stated that the training had helped her have a greater understanding of potential hazards in the home. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is suitably qualified and experienced to provide effective leadership in the home. The quality of care and the service provided is regularly monitored. Records are well maintained and stored confidentially. The Manager ensures that the health and safety of service users and staff is maintained. EVIDENCE: Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 23 Standard 31 The Manager is a trained nurse with many years of experience in nursing the elderly and has also completed NVQ 4/RMA (Registered Managers’ Award) in management. The manager gives a lead to staff in carrying out their duties, and in ensuring that service users are well cared for. The manager is assisted by a Deputy Manager who is the training co-ordinator, and who works some hours directly “on the floor” alongside nursing and care staff, and some supernumerary hours to oversee training and documentation. Standard 33 The home had systems in place for monitoring the quality of care via monthly reviews recorded on care files. Unannounced visits were undertaken regularly every month by the responsible person, as required under Regulation 26 and the reports of these visits were sent to CSCI. Regular meetings attended by residents were conducted and minutes of these meetings were retained to evidence their involvement and also to record the outcomes of any matters arising. A copy of the most recent inspection report was available and clearly on display in the reception area of the home and requirements and recommendations made at the previous inspection had been complied with. The home encourages feedback from both relatives and outside professionals and the manager ensures that she is visible to service users via regular “walk abouts” on the units in order to facilitate service users giving their views on the running of the home. Standard 35 This Standard was not assessed on this occasion. Standard 38 All staff had completed mandatory training in safe practices. Moving and handling training is carried out in house by 2 appropriately trained coordinators. Fire testing is carried out every week by the maintenance men, and includes checking that all doors close properly, and emergency lighting is working properly. They also carry out monthly visual checks on fire extinguishers, and checks water temperatures to ensure that thermostats are working correctly. Other duties, for example, include checking shower- heads, cleaning tumbledryers in the laundry, and checking hot trolleys for hot food storage window safety mechanisms and cot sides. Records were very well maintained. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 24 The Inspector viewed servicing records for all mobile hoists, the passenger lift, assisted baths, and PAT testing for electrical items. These were all up to date. Accident records are completed according to HSE requirements. These were satisfactorily completed. The Manager carries out individual audits for Service Users to check if falls become more frequent. Following a previous inspection recommendation a general audit of accident records is completed monthly, so that any pattern of accidents (e.g. time of day, person on duty) can easily be noted. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N0 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 OP22 Regulation 23 (2) c Requirement Ensure that there is always a staff member available to answer a call bell. Ensure any bad odours are dealt with as soon as practicable. Timescale for action 01/05/07 2. OP26 23 (2) d 01/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP19 Good Practice Recommendations Increased efforts should be made to assist and encourage one female resident to be attired in a dignified manner. The bathroom currently out of action should be repaired at the earliest opportunity. Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westcombe Park Nursing Home DS0000006775.V329903.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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