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Inspection on 24/03/06 for Westcroft

Also see our care home review for Westcroft for more information

This inspection was carried out on 24th March 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Some comments from the survey forms included: "The staff are very caring. We are welcomed warmly and staff work hard". "The staff are smiling and cheerful and know the residents well". "My friend was only there a few weeks but the standard of care was excellent". "The care at the home is very good". The staff were extremely helpful and co-operative during the inspection. The staff make a great effort to provide a stimulating environment with the use of themes and planned activities. The manager has a programme of supervision so that staff feel supported and enabled.

What has improved since the last inspection?

Orientation aids are now in the lounge and on bathroom doors. Control measures for the prevention of infection are now in place with the use of soap dispensers. The last two admissions to the home have been appropriate. Staff are being formally and regularly supervised. There are regular staff meetings where staff are consulted about life in the home. There has been an increase in the training attended by staff and this has helped them to update their skills.

What the care home could do better:

Some negative comments made by relatives on the comment cards were: "We sometimes have concerns over the level of heating provided in the cold weather and the use of appropriate clothing." "Depending on the staff working supervision of eating and drinking is very good but occasionally drinks are not given if out of reach." "Some adaptation staff could be asked to speak slower/clearer to enable those with poor hearing to understand". "The cleaning staff should have more hours". Some relatives commented that they did not know how to make a complaint, 6 out of 8 residents also said the same. The registered provider needs to make the service user guide a user friendly and up to date document reflecting the current legislation. This will include the complaints procedure. This then needs to be accessible and distributed to each resident and/or their representative. This ensures that everyone is aware of his or her rights, for example how to make a complaint. The registered provider needs to safeguard residents` monies by ceasing the practice of borrowing from other residents. An immediate requirement notice was issued to ensure that that stopped from the day of the inspection. The home needs to consistently evidence the involvement of the residents and/or their representatives in the drawing up and review of their care plan. A life history would also enhance the information assessed, and enable the staff to have a better understanding of each person. It should also increase the opportunity of providing some meaningful occupation. There are insufficient accessible bathrooms and toilets to meet the National Minimum Standards. The registered person needs to demonstrate that the available provision is suitable and does not cause any loss of choice, dignity and respect for any residents. The registered provider needs to promote independence and privacy for residents by providing door locks on bedroom doors, and lockable storage in each bedroom.The results of the Quality Assurance surveys and the action plan as a result of that survey should be published so that all interested parties are informed. The registered person or their representative needs to conduct monthly unannounced visits to the home and produce reports of these visits in accordance with Regulation 26. A copy of these reports then need to be sent to the manager of the home and to CSCI every month.

CARE HOMES FOR OLDER PEOPLE Westcroft 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS Lead Inspector Kathy Marshalsea Announced Inspection 10:00 24 March 2006 th 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 Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westcroft Address 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS 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) 01225 466685 01225 443367 Mrs Jean Uter To be appointed Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate 21 Patients aged 50 years and over requiring nursing care Staffing Notice dated 03/10/1996 Manager must be a RN on parts 1 or 12 of the NMC register May accommodate one named person with Mental Health needs. The registration will revert when this person leaves the Home. 2nd September 2005 Date of last inspection Brief Description of the Service: Westcroft Nursing Home is registered as a Care Home with nursing for 21 older persons. It is situated in Bath. The home is an older property with an extension. There is a mix of single, double rooms with one en-suite. These are set out over three floors. There is a passenger lift in the old wing and a chair lift in the new wing providing access to all service users areas. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and conducted by two inspectors. The manager was present for this. One inspector concentrated on looking at the environment. As part of the evidence gathering survey forms were sent by the CSCI to the home for relatives and residents to complete. Some of the comments in those surveys are used within the report. Time was also spent talking to staff and residents about their experience of life within the home. The inspection concluded with a feedback session for the manager. What the service does well: What has improved since the last inspection? Orientation aids are now in the lounge and on bathroom doors. Control measures for the prevention of infection are now in place with the use of soap dispensers. The last two admissions to the home have been appropriate. Staff are being formally and regularly supervised. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 6 There are regular staff meetings where staff are consulted about life in the home. There has been an increase in the training attended by staff and this has helped them to update their skills. What they could do better: Some negative comments made by relatives on the comment cards were: “We sometimes have concerns over the level of heating provided in the cold weather and the use of appropriate clothing.” “Depending on the staff working supervision of eating and drinking is very good but occasionally drinks are not given if out of reach.” “Some adaptation staff could be asked to speak slower/clearer to enable those with poor hearing to understand”. “The cleaning staff should have more hours”. Some relatives commented that they did not know how to make a complaint, 6 out of 8 residents also said the same. The registered provider needs to make the service user guide a user friendly and up to date document reflecting the current legislation. This will include the complaints procedure. This then needs to be accessible and distributed to each resident and/or their representative. This ensures that everyone is aware of his or her rights, for example how to make a complaint. The registered provider needs to safeguard residents’ monies by ceasing the practice of borrowing from other residents. An immediate requirement notice was issued to ensure that that stopped from the day of the inspection. The home needs to consistently evidence the involvement of the residents and/or their representatives in the drawing up and review of their care plan. A life history would also enhance the information assessed, and enable the staff to have a better understanding of each person. It should also increase the opportunity of providing some meaningful occupation. There are insufficient accessible bathrooms and toilets to meet the National Minimum Standards. The registered person needs to demonstrate that the available provision is suitable and does not cause any loss of choice, dignity and respect for any residents. The registered provider needs to promote independence and privacy for residents by providing door locks on bedroom doors, and lockable storage in each bedroom. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 7 The results of the Quality Assurance surveys and the action plan as a result of that survey should be published so that all interested parties are informed. The registered person or their representative needs to conduct monthly unannounced visits to the home and produce reports of these visits in accordance with Regulation 26. A copy of these reports then need to be sent to the manager of the home and to CSCI every month. 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. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 No service user moves into the home without having their needs assessed, but this information would be enhanced with the use of a life profile for each person. The handbook being used is not accessible for most residents or up to date so not everyone is well informed about their rights. Some orientation aids are now being used to increase independence and thereby better support the needs of people with dementia-type illness. EVIDENCE: 1. The resident’s handbook is not user friendly and needs to brought up to date to meet the current legislation. This will include a summary of the Statement of Purpose, a copy of the terms and conditions of accommodation to be provided and a standard contract. Some residents and relatives were not Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 10 aware of the complaints procedure so this would assist them to be aware of this. The most recent inspection report is not copied as part of this informastion – this is acceptable provided that it is made readily available in an accessible format. 3.Two new residents were case tracked. The information gathered to assess the suitability of the placement was sufficient to make that judgement. The Manager had completed the pre-admission assessments, and refused to take one person initially who was unwell and not suitable for the transfer. Although both new residents had Dementia the Manager had ascertained that this was not their primary need. The Manager is very clear about the categories of care that the home is registered for. Risks had been clearly identified and in one instance psychological problems identified. 4. It was reassuring to note that some orientation signs are now being used by the home to aid resident’s independence. This had been discussed at the last inspection. The pre-inspection questionnaire states that 8 residents suffer from Dementia but that their primary need is physical. The care of these residents must be based upon best practice and reflect relevant specialist and clinical guidance, for example person centred care. It was pleasing to note that one resident with dementia had began to look after a doll which had been brought into the home for another purpose. The staff had understood that this was a need for this resident and enabled this to continue. The manager stated that this had improved this resident’s quality of life. This is commended. The cultural needs of specific minority groups are respected. This was evident from discussion with the staff and reading a care file. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 11 Care plans are not always drawn up with the service user and do not often reflect social care needs. They also need to promote remaining abilities to maintain independence. Service users can be assured that they will be treated with dignity and respect at the time of their death. The staff need to be given a policy to be aware of how to deal with an unexpected death. EVIDENCE: 7. Three care plans with their accompanying assessments were read. Two were of recently admitted residents and one for a resident who had been at the home for some time. One plan was in effect a pre-placement care plan provided by social services. It contained good explanations of how to meet the assessed needs but did not promote remaining abilities despite these being emphasised in the preadmission assessment. The plan for dementia was not useful and needs to Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 12 give clear guidance about how to manage any problems. This plan did offer one interest the person had but no life profile was present to develop this further. The risk assessment for falls also needed greater clarity of how the risk is minimised and kept under review, as this resident had experienced some incidents of falls. Relevant health assessments had been appropriately recorded. It was noted that this plan would not be made into a complete care plan until the proper opportunity to assess had occurred, usually by the end of the first month of residency. The second plan was for the resident who had been at the home for some time. This was written in 2001 and had been regularly reviewed since then. It was possible to track the condition of this resident through the reviews. This plan may benefit from being re-written to include the most recent care and the actions needed to meet those needs. This should include a plan for the bereavement this resident had recently suffered, as it is a significant event. Although there was no social care documented staff were very clear about this person’s interests and how to support them in their life-style. The third case was a very recent admission and the care plan had not yet been developed. The home’s usual practice is to complete this after assessing the resident after they have been at the home for about a month. The information obtained before admission enabled the staff to meet the physical needs of this person. No care plans showed evidence of being reviewed with the involvement of the residents themselves or their representative. 11. The home had experienced a recent bereavement. Records showed that this death had been dealt with sensitively and with care and respect. The home had a policy for the care of the dying. This included instructions for dealing with the collapse of a visitor. If staff are being instructed to try and resuscitate then they should be given the equipment to do so. This was discussed with the Manager. There also needs to be a policy for an unexpected death. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully evaluated at this inspection: they will form part fo the focus of the next inspection. EVIDENCE: The following evidence was gathered in relation to Standard 15. The inspector had received a copy of the Environmental Health report dated 2/3/06. The contents of this report were followed up at this inspection. These covered the following: 1. Plans to make some improvements such as replacing the floor covering. 2. Proportional time needs to be spent to keep the kitchen up to a satisfactory level of hygiene. To aid this a new cleaning schedule is being devised. 3. There is also going to be some re-decoration to the stained ceiling and walls. 4. Update and expand the hazard policy. Recommendations were also made such as attendance at the Safer Food Better Business Course for the cook. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 14 The menus are 4 weekly and offer some choices. Residents spoken with said that they were satisfied with the food offered. Residents are asked what they would like to eat for lunch the day before. Some residents have a soft diet, which the cook stated are separated on the plate for presentation. The cook was able to discuss diabetic diets. The food stores confirm the menus. On the day of inspection there were limited choices in the food store for residents that may wish for an alternative. It was understood from the staff that quantities received are not always the quantities ordered. However there was no evidence that these difficulties have led to dietary inadequacies as alternative arrangements have been made at such times. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Some residents and relatives are not aware of how to make a complaint in the home. This must be made accessible and reinforced so that everyone is aware of their rights. The home’s policy for abuse must be updated and then include inter-agency local procedures. This will ensure that all staff respond appropriately if there are any allegations/suspicions of abuse. EVIDENCE: 16. There is a complaints policy and a copy of this in the front hall. This policy is also posted in the contracts and resident handbook. This needs to be updated to reflect the fact that the NCSC no longer exists (from 2002) and has been replaced by the Commission for Social Care Inspection (CSCI). Despite this 6 out of 8 residents who completed a survey from stated that they did not know how to make a complaint. Thought must be given to the accessibility of these documents. Alternative formats or reinforcement may be required for some residents. A record is kept of complaints and compliments. The record showed actions to be taken to resolve the issues. There were compliments from 3 visiting heath care professionals. 18.There is a policy for the subject of abuse. The home also has the BANES Inter-Agency Procedure for Protection of Vulnerable Adults. The manager was advised to use the BANES procedure for the actions to be taken in the event of Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 16 an allegation being made. This is because the existing policy does not include up to date information. The manger immediately took steps to record this on the policy, which will need to be updated. The core staff in the home have had training in this subject. The manager has requested a video about abuse for the adaptation staff. There is also a Whistle Blowing policy for staff to be able to safely report any suspicions of abuse. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The home is maintained to a reasonable standard but to improve and sustain the standard a routine plan of maintenance may be of benefit. The amount of communal space meets the National Minimum Standard for the number of residents but the layout of this space limits the potential for shared activities and private use. The home is not suitable for independent wheelchair users and does not enable people that require aids and equipment to move around the home independently. The ratio of toilets and bathrooms are limited by the lack of space, aids and adaptations so that most of these rooms are not suitable. The Statement of Purpose must therefore be clear about the facilities and restrictions of the building available at the home. The home was free from unpleasant smells. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 18 EVIDENCE: As you enter the home there is a front entrance with is one step into the porch and another step into the foyer, level access is through the side entrance. The property was extended to increase the number of people that can be accommodated and is known by the staff as the “new wing”. It is arranged over three floors, with bedrooms on all floors and shared space on the ground floor. While the building is maintained to a reasonable standard, bedrooms are showing signs of wear and tear. It is evident that repairs have taken place, although the cause of the problem remains unresolved and the repairs undertaken not returned to its original state. Examples of problems noted were of small holes in walls, cracks in basins, torn flooring or chairs and, in one bedroom, flooring not fitting properly. The details of these problems were passed to the manager during the inspection. There is no formalised routine programme of maintenance to protect the property from deterioration. Shared space consists of a lounge/dining room which measures . This room has a sitting area for 10 people to sit and socialize and a dining area with tables for 10 people to eat their meals. As the home offers accommodation for twenty-one individuals, the space is limited for the whole resident group to sit together and share activities. The lounge would benefit from redecoration, the carpet requires cleaning and must be incorporated into the cleaning schedule, the window is in need of repair and curtains must be replaced at the windows. It was noted that each chair has a table, offering easy reach for residents that have items that must be within easy reach. Toilets and bathrooms are provided on each bedroom floor. The ratio of people sharing the eight toilets is 2:3, as one double room is en-suite. The current ratio is above the NMS, but restrict residents that require assistance from staff, use aids and equipment because of their size. From observation of the staff and consultation, three toilets are not used for the residents because they are narrow and offer little space to manoeuvre. There are four bathrooms, which are shared by 21 people. However, three of these bathrooms are not assisted and not suitable so are not used. Only one bathroom is assisted and used by the residents. This means that some Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 19 residents have to be transferred across the home to use this bathroom. The registered person should consider the safety and suitability of this. There is a passenger lift used to the second and third floor of the “old wing” and a stair lift to the second floor of the “new wing”. Grab rails are provided in the corridors and a call bell system is provided. It is evident that the building is not suitable for people that require aids and equipment to move around the home independently. Most bedrooms are for single occupancy. Three bedrooms are double rooms with screens provided to maintain the individuals privacy. However, in one bedroom, two individuals were sharing the same wardrobe. Separate wardrobes must be provided for each person to respect and value the individuals’ rights to privacy and dignity. Some bedrooms are not lockable and have no lockable space within their bedrooms. In the extension “new wing” bedrooms are lockable and have lockable facilities. The manager must provide a detailed plan with timescales for providing lockable bedrooms. Bedrooms contain a combination of the home’s furniture and personal belongings, reflecting their personalities. Overall the premises were free from unpleasant smells. During the inspection, it was evident that the staff are committed to providing a clean environment. However, some bedrooms walls were dirty. Laundry facilities are sited away from the kitchen, the walls are painted and vinyl floors are provided, for easy cleaning. Within the laundry area, there is sluicing and hand washing facilities. The home handles soiled linen and waste disposal and sluicing is provided. The washing machine is industrial and has specific cycle for sluicing linen. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed at this inspection. They will form part of the focus of the next inspection. EVIDENCE: 27. There is a small core staff group, most of whom have worked at the home for a number of years. The other staff group consists of adaptation staff that are waiting to do their course, actually doing it or have completed it. This means that is a potential change of personnel every 6 months. It is stated by the proprietor that they usually stay for 8-9 months. The manager does not recruit these students but is responsible for monitoring their progress. The students are mentored by Mrs Uter who will be determining at the end of their course if they are competent practitioners. The manager has 15 hours supernummary per week to achieve the requirements of her role. This includes the induction of new staff, supervising them, managing the day-to-day events and overseeing the care planning. As the Deputy manager recently left the manager has no staff for which these tasks can be delegated nor does she have any administrative support. There is a key worker system, which could be more effectively used for quality time with their residents. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 21 Two care staff have their NVQ Level 2 and one is planning to do their NVQ 3. Three staff also hold a current First Aid certificate. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37,38 The manager is fit to be in charge and when empowered is able to discharge her responsibilities fully. Her management style is one of openness and inclusiveness. The Quality assurance survey results need to be published with an action plan to reassure residents that the home is being run in their best interests. Residents were not being safeguarded from financial abuse as staff were “borrowing” money from one resident monies for another. An immediate requirement notice was issued on the day of the inspection for that practice to cease. Policies and procedures should be brought up to date so that staff are aware of current practices. The regular testing of equipment and staff training is promoting fire safety. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 23 EVIDENCE: 31.Mrs Ramjutton has passed the fit persons interview with the CSCI.Records showed that she keeps herself up to date and is open to suggestions on improving standards and meeting requirements. She is also undertaking the Registered Manager’s Award. The manager is responsible for the clinical care and for the day-to-day running of the home. 32.Staff spoken with confirmed that they are regularly supervised on a one to one basis. Staff meetings are held regularly and the manager takes any suggestions made seriously. Staff spoken with stated that they felt that there had been improvements since the manager had returned and stayed in her post. The manager is able to demonstrate a clear sense of direction and leadership. 33. The Home has begun to establish a Quality Assurance program, which has resulted in an outcome letter. This was sent to the manager from the proprietor. The results showed that some areas need improving such as the cleanliness and the handbook. The detail of the comments should also be available. This should lead to an annual development plan based upon these findings, which should be available to residents and other interested parties. 35. The records of residents’ monies were checked. The monies are kept in separate containers with individual books. The books showed that money is being borrowed without the permission of the residents, which was returned later. This borrowing must cease straight away so an immediate requirement was made to that effect. The Manager stated that she had requested that staff do not borrow and had put a notice on the accounts book to that effect. Three containers were checked to ensure that the amount held tallied with the amount recorded. They did. Two signatures were present for all transactions. No residents control their own finances. The business and financial plan will be checked at the next inspection. 37.It was noted from the pre-inspection questionnaire that may of the home’s policies and procedures were written in 2003.It is recommended that they are all reviewed annually. 38. The Fire Log was checked. Safety tests are being conducted at the recommended intervals, including drills. Training was given to staff recently by an external trainer which 14 staff attended. Updates are given via a video and questionnaire. Risk assessments are being completed for each wing. So far these show a low level of risk. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 24 Generic risk assessments are also being completed. One bedroom has a trailing call bell lead and needs to have the risk of this assessed. Infection control measures have been improved with the provision of soap dispensers in all bathrooms, toilets, bedrooms, kitchen and the laundry. Regulation 26 reports, which should be conducted by the registered provider, are not being received by the CSCI. This must be done in accordance with this regulation. Regulation 37 reports are being sent to the CSCI in accordance with this regulation for any incidents/accidents which could adversely affect the residents. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 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 2 X 2 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 2 2 2 2 2 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X 2 2 Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1)(2) Requirement Draw up care plans with the resident and/or their representative. This is a repeated requirement. Update the Workplace Risk Assessment for fire safety annually or as conditions change within the home. a) Ensure the Service User Guide includes the information recorded in Standard 1 of the report and is given to each service user. b) Ensure the Statement of Purpose reflects the facilities available and the restrictions of the environment and complies with all other aspects of Schedule 1. Complete a risk assessment for the bedroom identified during the inspection with a trailing call bell lead. Ensure the complaints procedure is clear and accessible for all residents. Ensure the home is kept in a good state of repair internally. DS0000020315.V271747.R01.S.doc Timescale for action 20/06/06 2 OP38 23(4)(v) 31/07/06 3 OP1 4&5 Schedule 1 30/09/06 4 OP24 12(1)(a) 31/03/06 8 9 OP16 OP19 22(2) 23(2)(b) 30/06/06 31/07/06 Westcroft Version 5.0 Page 27 10 OP21 12(1)(a) 11 12 13 14 15 OP24 OP24 OP35 OP33 OP31 16(2) 12(4)(a) 12(4)(a) 17(2) 24(2) 26 Send a risk assessment with the action plan to show the suitability of only having one suitable bath for 21 residents. Ensure residents do not share a wardrobe. Provide lockable storage in each bedroom for each resident. Ensure monies held in safekeeping are not used for other residents. Make a copy of the report of the review of quality assurance available to each resident. The registered provider or their representative shall visit the home in accordance with this Regulation and provide a copy of this report to CSCI and to the manager of the home. 31/05/06 14/05/06 30/10/06 24/03/06 30/09/06 31/05/06 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 3 4 5 6 Refer to Standard OP7 OP8 OP11 OP24 OP33 OP37 Good Practice Recommendations Draw up life histories during the care planning process so that a holistic plan is formed. Provide suitable equipment if staff are expected to do any form of resuscitation. Develop a policy for an unexpected death. Fit locks to bedroom doors. Produce an annual development plan following the quality assurance surveys. Keep policies and procedures up to date via regular review. Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Westcroft DS0000020315.V271747.R01.S.doc Version 5.0 Page 29 - 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. 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