Inspection on 01/11/07 for Westcotes Rest Home

This inspection was carried out on 1st November 2007.

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

The inspector 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

Westcotes Rest Home 13/09/06

Westcotes Rest Home 10/01/06

Westcotes Rest Home 04/10/05

Westcotes Rest Home 08/12/04

Westcotes Rest Home 03/08/04

Westcotes Rest Home 26/11/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westcotes Rest Home 113-115 Hinckley Road Leicester Leicestershire LE3 0TF Lead Inspector Thea Richards Unannounced Inspection 10:00 1 November 2007 st 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 Westcotes Rest Home DS0000006416.V347291.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. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westcotes Rest Home Address 113-115 Hinckley Road Leicester Leicestershire LE3 0TF 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) 0116 233 2919 0116 299 4384 care@westcotes.co.uk Mr Les Downing Mr Les Downing Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To be able admit the person of Category MD named in variation application number 34009 dated 4th July 2002. 13th September 2006 Date of last inspection Brief Description of the Service: Westcotes Care Home is a care home providing personal care and accommodation for 20 older people with a physical frailty. The Registered Provider Mr Les Downing owns the home. Mrs Lisa Haynes has been the acting manager for two months. The home is situated on Hinckley Road close to shops, public houses and bus routes, which lead to the centre of Leicester. There is limited parking in the road outside the home. The accommodation is in two converted Victorian houses, which has provided spacious accommodation. There are three lounges, one dining room and one double bedroom located on the ground floor. The remaining bedrooms (two doubles and fourteen singles) are located on the first and second floors and are accessible either by passenger lift or stairs. The home is well maintained and provides a safe, comfortable and homely environment for the residents to live in. Outside, there is a well – maintained patio area with patio furniture and tubs of plants and flowers, which is easy to reach for the residents in the better weather. The current registration certificate from the Commission for Social Care Inspection is available in the reception area with an up to date insurance certificate. The latest report from the Commission for Social Care Inspection is available in the managers’ office. The home can be contacted by telephone or fax. Current fees at the home are in line with the local authority rates. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 5 There are extra charges for hairdressing, chiropody, newspapers and personal items. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit the inspector spent five hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 13th September 2006. This included the Annual Quality Assurance Audit completed by the home and surveys completed by the residents, their families and the staff. The visit took place on the 1st November 2007 and lasted seven hours. During the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to three of the residents. To achieve this, the residents and their families were spoken with. The inspector spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission, the residents’ bedrooms were looked at. The inspector also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The inspector looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. The inspector looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit the inspector spoke with the manager, staff, the residents and their families, a visiting District nurse and a chiropodist. What the service does well: Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 7 The service provides a caring, committed staff who give care with dignity and privacy in a family atmosphere. The staff are trained to give the residents the right care an there are sufficient numbers of staff to give this care. The home provides homely and safe accommodation for the residents. Excellent food and choices are provided. What has improved since the last inspection? What they could do better: The Statement of Purpose, the service user guide and the complaints policy could be produced in other formats to make them easy to read and understand for a wider group of people. When prospective residents are assessed a form should be developed to record the information collected. The entries in the daily record should be completed more frequently and the content be clear and detailed, to give the staff a better understanding of the resident’s day. The staff who administer medicines should have some updated training. The medicine records for controlled (dangerous) drugs must always be completed to make sure that they are being given correctly. Activities that the residents take part in or not should be documented to confirm that they have choices in doing what they wish to. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 8 All staff should have a completed application and references in place before they start working in the home, which will make sure that they are suitable people to be employed in a care home. An application should be made to register the manager with the Commission for Social Care Inspection as a ‘fit’ person to have the managers’ post. Consideration should be given to giving the manager time to undertake her management responsibilities. Formal supervision for the staff should be put in place to allow the staff to have time with their manager to discuss work and training needs. The staff should have regular meetings with the manager and/or the provider, which have minutes taken and will allow them to discuss issues associated with the residents and the home. Systems should be put in place to monitor and consult with residents, their families and any other interested parties to make sure that the registered person can respond to comments and responses. 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. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 9 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 Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are assessed before moving into the home and they are offered the chance to visit the home. They are given adequate information to allow them to make an informed choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had been given a Statement of Purpose, service user guide and a copy of the terms and conditions. The registered provider should make these documents available in alternative formats such as large print and other languages, which will make sure that a wider group of people can understand the information. Providing a comprehensive Statement of Purpose & Service Users’ Guide results in good information for the residents, making sure that they they can get the most suitable care. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 11 The acting manager visits all prospective residents before they are admitted to the home, but does not complete a pre admission assessment form. She should produce a form which contains the information needed to make sure that the home can meet the prospective residents needs. This will make sure that that the staff in the home have the the right information, so that the resident gets the best care. The resident meets someone from the home who they can recognise, which makes the move into care easier to manage for them. The families spoken with confirmed that they were given the opportunity to visit the home before their relative came in. Members of the staff spoken with said that they knew what the residents needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home. The latest report from the CSCI was available in the managers’ office. An up to date insurance certificate was displayed in the entrance hall. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff meet the care needs of the residents as identified in the care plans and give them privacy and dignity with their care. Records do not always support the care being given. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in them, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor and other health professionals when they needed to. There are records of the residents weight held in a separate file, which makes sure that they are not having an unexplained weight loss or gain. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 13 The resident or their families had seen and had agreed with the care plans and those spoken with, said that they had been involved in the review process and were happy with the care being given. The daily record of care was found not always to be up to date which makes it difficult to make sure that the residents receive the right care and the staff may not be aware of what has happened to them during the day or night. The daily record of care should be completed on a regular basis and contain information which is clear and accurate as to how the resident has spent their day. The inspector saw the residents being treated with dignity and respect when staff spoke with them and gave them their care. Staff seen giving care did so in the right way, giving the residents privacy where needed and communicated with them whilst giving the care. The staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. A comment from a resident was that ‘ everybody was lovely and the care couldn’t be better’. A visiting chiropodist and a district nurse were spoken with and both said that the residents were well –looked after. They said that if the staff found any problems with the residents they always referred them to the relevant professional staff and that any instructions were carried out, as they should be. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had some training to give medicines. The manager should arrange further training from an outside provider to up date the staff. The medicine round was seen by the inspector and medicines were administered individually and the residents seen to be taking them. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The manager regularly looks at the record sheets and records that these have been checked. The controlled (dangerous) drugs were checked and found to be in order, however there were three entries, which had either not been signed or countersigned. There is a policy for residents handling their own medicines, but there are currently no residents in the home doing so. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their social, spiritual and nutritional needs met. Their views are taken into consideration and acted on, but this may be helped with some formal meetings and quality reviews. EVIDENCE: There was some evidence of activities being provided for the residents, these mostly happened on an informal ‘family’ basis. They have a ‘music man’ visit the home monthly, which the residents all said that they enjoyed. The residents and the families spoken with were happy with the amount and variety of activities arranged. There was no written evidence in the care plans or separately that activities were happening. During the visit the residents were seen to be chatting with the staff and with each other. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 15 There were several visitors in the home on the day of the visit and those spoken with were positive about the communication with the manager and said that they were always made very welcome in the home. The welcome given to visitors was seen by the inspector on the day of the visit. The residents have a choice of meals every day and the staff are able to offer the residents alternative, individual choices if there is nothing the resident likes. The inspector spent time the dining room during lunchtime and the meal looked very appetising and plentiful. All the residents spoken with said that they were enjoying their meal and that they always had a choice. The staff have a good understanding of the dietary needs of the residents including diabetic diets. The staff were seen to be sitting and talking with the residents during the meal. The manager sees each of the residents on a one to one basis every day. There are regular informal meetings with the residents and families are seen and spoken with regularly. There are no minutes taken for any of the meetings and the home does not currently send out quality questionnaires. Regular meetings with minutes and questionnaires would make sure that all of the residents and families will have their views heard and help the home to make any changes that may be needed. Religious needs are provided for, with a monthly service and a priest who visits regularly. A hairdresser visits the home regularly, which the residents enjoy. Westcotes Rest Home DS0000006416.V347291.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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place, which gives the details of how to complain and who to complain to if they needed to. Consideration could be made to produce the policy in other formats such as large print or other languages, which would make it easier to understand. The complaints book was looked at and was found to have an adequate record of any complaints received and when they were resolved. There have been no recorded complaints since the last inspection 13th September 2006. The Commission for Social Care Inspection (CSCI) has not received any complaints since the last inspection. The residents spoken with were happy that they would speak to the manager or a member of staff, if they had a problem and that it would be dealt with. Families spoken with on the day of the visit said that they were aware of the procedure to complain and would have no concerns about doing so. The staff spoken with knew how to deal with a complaint, which was given to them. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 17 The staff said that they had had training in safeguarding adults, which was confirmed by the training records held in the home. The staff spoken with told the inspector how they would handle such an incident and that they would have no concerns about ‘whistle-blowing’. This makes sure that the residents are safe from any abuse and that any concerns are handled correctly. The home had information displayed for the residents as to how they could find an advocate to act on their behalf if they had no one else and they wanted one. This is good practice. Westcotes Rest Home DS0000006416.V347291.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): 19, 23, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a pleasant home, which is run in their best interests. A comfortable, clean and safe standard of accommodation is provided for the residents. EVIDENCE: Westcotes Rest Home is made up of two, three- storey Victorian houses, which have been converted to provide the accommodation. A passenger lift, stair-lift or stairs access the upper floors. There are three lounges and a dining room, giving the residents a good choice of where they wish to sit. There are television and music centres in each lounge area. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 19 The home is well maintained, clean and free from any unpleasant odours, giving the residents a pleasant place to live in. The décor could be updated to make the home brighter, but the residents are happy with it at present. There is a pleasant patio area, which is easy for the residents to get to in the better weather. The bathrooms are clean, tidy and free of any hazards. One bathroom did have some unnamed toiletries in it, which could be a hazard for the residents if someone who is confused drank them. They could also cause cross infection if used for more than one resident. This was shown to the manager, who had the items removed before the end of the visit. With their permission, the case tracked residents bedrooms were looked at by the inspector. They provided good accommodation, which had been personalised with the resident’s belongings. The bedrooms were clean and well maintained. The shared bedrooms provided screens and separate areas for storing clothes and belongings to make sure that the residents had the privacy that they should have. Sharing rooms was discussed with the residents and their families before they were admitted and this was documented in the care plans. There was evidence of equipment such as hoists having been provided to help in the care and comfort of the residents. The cleaning materials were kept in locked cupboards and the staff have had training in handling dangerous chemicals. The fire records were being completed regularly and were found to be up to date. The records for the testing of the hot water could not be found and the manager agreed to send them to the inspector. There were no further outstanding safety or maintenance issues seen on the tour of the premises. The registration certificate from the Commission for Social Care Inspection was displayed with a current certificate of insurance. The inspection reports are available in the managers’ office. Westcotes Rest Home DS0000006416.V347291.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): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are met and their safety protected by the recruitment policy and by the training that is in place. There are enough staff at the home to provide for the residents needs. EVIDENCE: There is evidence of a good skill mix of staff to make sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and relatives spoken with felt that there were always enough staff on duty to look after them properly. Two staff files were looked at by the inspector and the required information was complete in one of them. This included evidence of identification, adequately completed application forms, two written references and a Criminal Records Bureau (CRB) check. The second file did not contain any references or an application form. There was a CRB and working visa present in the file. A requirement was issued for the registered individual to comply and produce these documents within a week, these documents have now been sent to the inspector. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 21 There were records of staff training including induction and the staff spoken with confirmed that they received regular training in moving and handling. They said that they had training in first aid, food hygiene and medicine training. The home has more than the required level of staff with a National Vocational Award (NVQ) at level 2 or above and is to be commended. There was no evidence, such as minutes seen, that staff meetings are held. Staff said that they saw the manager daily and discussed any issues. The manager has completed a National Vocational Award at level four and is shortly going to begin the training for a registered managers’ award. The National Vocational Qualification is a qualification for care staff to make sure that they receive the right training in the needs of the resident group whom they are caring for. Westcotes Rest Home DS0000006416.V347291.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): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is committed to the best care for the residents, but needs to improve records and information to achieve this. EVIDENCE: The manager was available throughout the visit to the home. The manager is a new manager who has been in post for two months. She has completed a National Vocational Award at level four and is hoping to start her Registered managers’ Award shortly. An application to the Commission for Social Care Inspection to be the Registered manager has not yet been made. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 23 This is a process to make sure that managers are ‘fit’ people to manage a service. There was no evidence in place that regular staff supervision was in place, the members of staff spoken with confirmed that they had not received regular supervision, but that they saw the manager very often. Formal staff supervisions should be stated to meet the Care Standards requirements. The process of formal supervision time gives the staff and their ‘line manager’ the opportunity to have individual discussions about work and training needs. The manager spends much informal time with the residents, their families and with the staff, which was confirmed by all of those spoken with. She must put documentation in place to confirm that meetings have taken place and that issues that are raised are noted and dealt with. Annual questionnaires to gain peoples views about the service should be put in place. These practices will allow the manager and the responsible person to respond to the residents and the staff’s needs. The responsible individual should consider giving the manager supernumerary time to allow her to complete the responsibilities required for a manager. There are accounts held to manage the residents personal allowances and are being managed correctly with two signatures and the receipts in place. The policies and procedures are in place for the home and are regularly reviewed. They are available for the staff to read to make sure that they know how the residents are to be cared for and protected. All of the notifications (Reg. 37s) that the Commission for Social Care Inspection has received since the last inspection on 13th June 2006 have been dealt with correctly. Records for the maintenance of fire equipment, fire drills and training were found to be in place and up to date. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 24 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 1 2 3 Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 (2) Requirement That the controlled drug register is signed and checked that the required two signatures are present. That all staff employed at the home have an application form and two references provided before they start working at the home. The Registered Provider must appoint a Registered Manager to manage the service. The manager must make sure that a programme of formal staff supervision is put in place at the frequency required by the Care Standards act. Timescale for action 01/11/07 2. OP29 19 (1) (b) (i) 08/11/07 3. 4. OP31 OP36 11 (1) 18 (2) 01/01/08 01/01/08 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 OP1 Good Practice Recommendations That the Statement of Purpose and service user guide can DS0000006416.V347291.R01.S.doc Version 5.2 Page 26 Westcotes Rest Home 2. 3. 4. 5. 6. OP3 OP7 OP12 OP16 OP30 7. OP31 8. 9. OP36 OP37 be produced in other formats. That a form should be developed to record the pre assessment information collected. That the daily record is completed at more frequent intervals and with clear and detailed information. The activities that the residents take part in should be documented in the care plans. That the complaints policy can be produced in other formats. That the staff who are undertaking the administration on medicines are given up to date training by an outside trainer. The registered individual should consider giving the manager time to undertake the duties required by a manager. That the manager holds regular meetings with the staff that have minutes taken. Systems should be put into place to monitor and consult with the residents, their families and any other interested parties and records kept of the results. Westcotes Rest Home DS0000006416.V347291.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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