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Inspection on 13/06/07 for Westcroft Nursing Home

Also see our care home review for Westcroft Nursing Home for more information

This inspection was carried out on 13th June 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.

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

This is a small nursing home providing a highly personal level of care with close relationships between residents, staff and visitors. The Manager works hands-on in the home and readily available to residents and visitors. Similarly the provider has an almost daily presence in the home and he too is readily available and accessible. Flexibility of routines is evident. Residents spoken to confirmed their chosen lifestyles are known and pursued by staff. Quality of life is augmented by an excellent individual activities programme tailored to the needs of people, mainly on a 1:1 basis as required. There is a very relaxed and homely atmosphere, being a small home all visitors know staff, owner and manager and there are friendly, welcoming and very relaxed engagement. Many residents have complex healthcare and other needs which are met by a very committed and well trained staff group. Staffing levels are good and nursing care provided and support from care staff and adequate numbers of other support staff.

What has improved since the last inspection?

What the care home could do better:

The Statement of Purpose/Service Users Guide must be updated to reflect the current service and facilities offered by the home. This should be readily available to current and prospective residents. Although much progress has been made, some further work is needed on the environment but the home have applied to purchase new bedroom and dining room furniture as part of the Government Grants available to all private homes. This would further enhance the very positive improvements already made. Bleach and other COSHH items must be removed from areas where residents have access to them. They must be securely stored to ensure safety of residents. The toilet areas near to the reception area should be upgraded and cleaning routines reviewed. Further screening should be considered to ensure privacy of use of the toilet areas. Many bedrooms have good personalisation reflecting individuality some do not and this should be addressed. Prescribed creams should be removed from bedrooms or stored there securely.

CARE HOMES FOR OLDER PEOPLE Westcroft Nursing Home 5 Harding Road Hanley Stoke-on-trent Staffordshire ST1 3BQ Lead Inspector Peter Dawson Unannounced Inspection 13th June 2007 09:00 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 Nursing Home DS0000026970.V338973.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. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westcroft Nursing Home Address 5 Harding Road Hanley Stoke-on-trent Staffordshire ST1 3BQ 01782 284611 01782 215265 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) None Pradeep Arvind Patel Mr Devdutt Meethoo Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (27), Physical disability over 65 years of age (3) Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2006 Brief Description of the Service: Westcroft Nursing Home is a small nursing home providing personalised care for up to 27 people. IT is located close to Hanley town centre and is a large pre-war house with purpose built 2 storey extension. There are 17 singe and 5 shared bedrooms, 18 having en-suite facilities. There are 2 bathrooms (one assisted) and walk-in shower room. There are 3 lounges, a conservatory, separate dining room and the usual office, kitchen and laundry facilities on the ground floor. There is a shaft lift to the first floor and there is a small attractive garden/patio area for residents use. Bedrooms are located on both floors and there is a shaft lift access to the first floor. The home provides care with nursing for up to 27 people, some of whom may have a physical disability, mental disorder or dementia care needs. The home is staffed by nurses at all times and supported by care assistants and supportive auxiliary staff. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on one day by one inspector from 8.30 – 4.30 pm. The Annual Quality Assurance document (AQAA) was not returned to the Commission prior to the inspection as required. Information in that document is therefore not included in this report, nor was it possible to obtain written feedback from residents or relatives. There was an inspection of the whole of the communal areas and a sample of bedrooms. A range of documents were inspected including care plans, medication records, complaints, staff files and rotas and other documents relating to the inspection process. There were 25 people in residence at the time of the inspection and there were 3 vacancies, which is unusual for this home but pending admissions were in process. Most residents were seen and many spoken to including 3 people who were bedfast. One resident who is bedfast said that she was cared for very well by staff, they were helpful, respectful and attentive and she had no complaints. Comments from other residents included “I am happy here, the food is good and they look after you”. “I am not well, but if I tell the staff they talk to me and explain what they are doing to make me better”. There was a focus during this inspection upon health care needs, recording and practice. Some shortfalls had been found on the last key inspection in this area and requirements made. However, the home have addressed all the areas identified and made changes by improving clinical practice and recording to good professional standards. Further changes and improvements to the physical environment have addressed shortfalls also in that area. The home have worked hard to achieve the positive results they have aimed for. Fees charged for nursing care at Westcroft are £450 per week. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? At the time of the last key inspection in November 2006 13 requirements were made and 3 recommendations. These centred around recording an practice in clinical matters including pressure area management, nutrition, medication administration and aspects of the environment. All residents are now receiving a free chiropody service from the NHS – previously there was only a private service. Medication administration has improved with better recording of PRN medication, photographs on MAR sheets and allergies recorded. Fluid intake charts are now totalled daily, monitored by nursing staff and any concerns or shortfalls referred to the GP. To improve hydration all bedrooms now have new trays with drinks available throughout the 24 hour period. Staff feel that this has improved hydration for some residents who previously did not have drinks during the night-time. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 7 All residents are now weighed monthly following requirements and where there are concerns about weight loss are weighed weekly. Improvements in the recording of tissue viability care have been made. Body mapping charts have been provided to record site, size, grade and treatment of pressure sores. This more clearly monitors progress of treatment and meets current professional standards. The use of the communal areas has been reviewed and significant changes made. The conservatory, little used previously has been integrated with the main lounge area, providing additional useable space, increasing natural light in the main lounge area and providing a facility used by residents and visitors who have a view of the garden and patio area. This is an excellent change and vast improved use of the space available. Cleaning routines in the dining area have been reviewed with good outcomes. New serving trolleys and other equipment have been purchased, improving the facilities and general hygiene. What they could do better: The Statement of Purpose/Service Users Guide must be updated to reflect the current service and facilities offered by the home. This should be readily available to current and prospective residents. Although much progress has been made, some further work is needed on the environment but the home have applied to purchase new bedroom and dining room furniture as part of the Government Grants available to all private homes. This would further enhance the very positive improvements already made. Bleach and other COSHH items must be removed from areas where residents have access to them. They must be securely stored to ensure safety of residents. The toilet areas near to the reception area should be upgraded and cleaning routines reviewed. Further screening should be considered to ensure privacy of use of the toilet areas. Many bedrooms have good personalisation reflecting individuality some do not and this should be addressed. Prescribed creams should be removed from bedrooms or stored there securely. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 8 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. Westcroft Nursing Home DS0000026970.V338973.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 Westcroft Nursing Home DS0000026970.V338973.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): Quality in this outcome area is adequate The Statement of Purpose/Service Users Guide has not been update for sometime, information is dated and inadequate and this must be revised/extended. Pre-admission assessments and visits by residents/relatives are normal practice. Needs are identified and form the basis of care planning. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose/Service Users Guide is out of date and must be updated to reflect the currents service and facilities offered by the home. Copies are not readily available and must be made available to all current and prospective residents, their families and other professionals as required. An updated copy must be sent to CSCI. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 11 Sponsored residents have contracts provided by the Local Authority, selffunding residents have contracts provided by the home. Prospective residents are assessed by the home prior to admission and Care Management Assessments are also obtained. These were present in the care planning information seen in relation to 2 recently admitted residents. Where possible pre-admission visits are made by residents, although this is not always possible for many reasons. Relatives are always involved in arrangements and visits to the home prior to admission. Care plans are based upon assessments made prior to admission and are progressive and reviewed regularly. Reviews are carried out 6 weeks after admission to confirm suitability of the placement and confirm permanent residency. This home does not provide intermediate care. Westcroft Nursing Home DS0000026970.V338973.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): Quality in this outcome area is good. There has been considerable improvement in areas of clinical recording and practice identified in the last report. This also applies to medication administration. Health and personal care needs are clearly identified and are now fully met. The privacy, dignity and respect of residents by all staff is evident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last key inspection some areas of clinical recording and practice needed improvement. Requirements were made and improvements have been made in those areas. Improvements include: closer monitoring of fluid intake charts and referrals to GP where there are shortfalls. All bedrooms now have trays with drinks throughout the 24 hour period to improve the intake particularly throughout Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 13 the night of residents with hydration/nutritional needs. A member of the nursing staff has also been involved in a course run by the PCT for the assessment and recording of nutritional needs. Recording of pressure area management has improved with body maps, charting and grading pressure ulcers and their treatment and progress. Regular weighing of residents was sometimes not consistent – all residents are now weighed monthly and those nutritionally at risk weighed weekly. Charts were sampled and much improved. There is presently only one incidence of pressure management required in relation to a recently admitted resident with some evidence of this upon admission to the home. Records showed good recording, treatment and management to professional standards. All residents now have the benefit of the NHS Chiropody Service, previously there was a mixture of private and payments by the home. This service has improved and standardised the availability to all residents of a free service. A sample of care plans were seen to be based upon pre and post admission assessments. Plans are reviewed monthly and changes to care plans are made identifying changing needs. Plans seen all had assessments for nutrition, waterlow, moving & handling and details of all aspects of personal care needing support from staff. Medical conditions were identified in care plans in some detail with list of medications prescribed and relevant. A diagnosis of learning disability was questioned in one instance - the inspector having had a lengthy conversation in detail with the person at an advanced level about politics, the Royal family’s role in society and world travel. There was a discussion with the Manager about diagnoses v labels and the need to verify all information in the interests of residents. Requirements made at the last key inspection relating to medication had all been addressed. Medication records had been accurately completed and checks showed no deficiencies in this area on this visit. However a shortfall previously identified did still exist which was prescribed creams left in several bedroom areas. These were removed to the medication storage room and the need for this will be re-enforced with staff. There are presently no facilities for secure storage of medication in bedrooms, although it is hope that planned bedroom furniture replacements will include this facility. At this time there is no self-medication in the home, there have been no requests or considered suitability. There is evidence observed and confirmed by residents spoken to that staff treat them with respect and privacy. An interesting changed observed in practice was that portable screens are now used whilst transferring people with the use of the hoist in the lounge areas this ensures privacy and dignity from other residents/visitors present. Westcroft Nursing Home DS0000026970.V338973.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): Quality in this outcome area is good. Individual lifestyles are promoted. Social and recreational needs are met with a very positive activities programme tailored to individual needs. There is no pastoral care provided and views of residents should be sought. Visits by family/friends are encouraged and many are usually seen in this home. Food provision is good and satisfaction expressed by residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Dependency levels are high which may sometimes limit choices which may be made because of high physical needs or mental health needs. The home nevertheless attempts to provide the required chosen lifestyle. Ways of ascertaining the wishes and choices of some residents unable to express their views were discussed with the Manager during the inspection and it was agreed that choices and preferences known to some but not all staff - could be recorded in care plans. An example was the preferred night care routines for some residents unable to express their views verbally. Choices such as Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 15 preferring rising/retiring times and food were recorded in care plans and this could be extended. Residents able to express a view said that they were happy with the care provided at Westcroft, spoke highly about staff care and said that they were satisfied with their lifestyle. There is an excellent activities programme in this home, run by two of the nursing/care staff who have specific allocated time for this purpose. Activities are discussed, agreed and recorded and the diverse needs of this group, many with high dependency needs are met in a very positive way. Many activities are provided as needed on a 1:1 basis this includes for instance 3 people presently bedfast. This is a positive strength in this home which improves quality of life for residents. One area that may be improved is provision of pastoral care for residents. There are no regular clergy visits. Previous visits by Roman Catholic priests have been made, but there are currently no residents needing this service. The Manager reports that no requests have been made for pastoral care and routine visits by clergy do not appear readily available. The views and needs of residents in this area should be sought. Contacts with families are promoted and clearly seen as an integral important part of care. Many visitors have been spoken with on past inspections. On this visit it was not possible to speak to visitors but time was spent speaking to many residents, the flexibility of routines to meet their needs was confirmed by those spoken to. There have been changes to menus and food provision with input from residents. On the day of inspection there were choices at the 2 mealtimes observed. Residents were eating cooked breakfast at the start of the inspection and there was a good choice of 3 courses for the main mid-day meal. Residents confirmed their satisfaction with food provision. Westcroft Nursing Home DS0000026970.V338973.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. The complaints procedure is satisfactory and available. Complaints are taken seriously and acted upon. A recent unsubstantiated adult protection referral has confirmed and strengthened the procedures in place and been used as a positive learning experience for all staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure posted in the home for residents and visitors, this is clear and concise. A copy will be included in the revised Service Users Guide required and given to all residents/relatives. A complaint received last year by the Commission was partly upheld and matters relating mainly to the environment were adequately addressed. Complaints are considered positively by the home as a means of improving the service they provide. No complaints have been received directly by the home in the past year. One referral relating to poor care/possible abuse was made under the Vulnerable Adults Procedures following the admission of a resident to hospital. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 17 The Manager attended VA strategy meetings and provided a comprehensive report to the meeting. The outcome was that the allegations were unfounded. This experience was used positively by the Manager as a learning experience for staff in ensuring good recording and attention to detail relating to the health, care and condition of residents. Any conditions or instances that may be construed as potential harm to residents are immediately notified to the Manager. All staff had had training in the Protection of Vulnerable Adults prior to the above referral and this has been re-enforced. Westcroft Nursing Home DS0000026970.V338973.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. Considerable improvements have been made to all parts of the environment over the past year. The use of communal space has been changed, improved and maximised for all residents. This has improved quality of life for many. Further improvements are planned. Hygiene could be improved also in further areas. Bleach must be securely stored to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been considerable necessary improvements and upgrading to the environment over the past year. All the communal areas have been recarpeted and redecorated. This applies also to many bedrooms and corridor areas on the first floor. Double glazing has been completed for all areas of the building. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 19 The call-system was old and requirements made previously to modify and provide extensions to the system. Since the last inspection a new call-system has been installed at a cost of £7,000 this has improved the effectiveness of the system and there are extension leads in bedrooms for easy access. It was noted that the system in the lounge areas did not have extensions for resident use. It is suggested that these are provided so that perhaps nominated residents in each area can use the system for the benefit of residents in the particular area this would maximise the use for residents of an expensive new system. It is presently not accessible to or used by residents in the lounge areas. Some of the communal areas were previously little used by residents, most being located in an inner lounge with little natural light and no external view, the home were asked to review the use of lounge areas and maximise its use for all residents. This has been done. The conservatory with good views of the garden/patio area was used as the smoking area and storage of wheelchairs etc. This has been opened up to extend the lounge area and made a dramatic difference to access and use of this very pleasant area. The smoking area relocated to a small lounge area and shed provided to house equipment. Several residents were seen accessing this area and some confirmed the improved use and improvement in the natural light and views from the inner main lounge area. Some areas of the home required changed cleaning routines to improve presentation and hygiene one area was the dining area. This has been done, new equipment purchased, the area redecorated and general presentation improved. All areas of the home were inspected on this visit including a sample of single and shared bedrooms. Many bedrooms were well-personalised but not all. A room without any personalisation was discussed and the Manager will take steps to change this by means of key worker, family involvement or provision of items to individualise the room. In some bedrooms over-bed lights required attention, in others there was no bedside light. This will be reviewed in all bedrooms. Some new bedroom furniture has been provided but many other rooms require new furniture. The Provider has made application for new government grants available to private homes which would allow new bedroom furniture in many rooms and also new dining room furniture which would further enhance the improvements already made there. Clearance and improved cleanliness is required in the laundry area. The sink area was littered with paintbrushes etc used for redecoration. This should be cleared and cleaned. It was noted that bleach and white spirit were left in this area which is not locked and is accessible to residents. These items must be removed immediately. Also bleach was seen left unattended in a cleaning bucket in a bathroom area. These items present a potential risk if accessed by Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 20 residents, should be appropriately stored and staff advised on the risks to residents. The home may also wish to consider the use of sanitizer products as an alternative to bleach with a lower risk potential. A used safety razor had been left in a bathroom its ownership unknown Staff must be made aware of the potential risks to residents and also cross-infection risks if used by other residents. The vinyl flooring in the kitchen area has been replaced and improved infection control in this high risk area. The obvious area requiring further improvement is in the main toilet areas adjoining the reception area. The toilets are stark with poor hygiene standards and vinyl flooring rising and cracking. These areas have large opaque windows but it is possible to see into the lounge area opposite them. In the interests of privacy and dignity additional screening of the windows is needed. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 21 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. Good staffing levels. Good staff training with clear commitment to resident care. Recruitment procedures protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels have been consistently maintained and increased in this home. There are adequate numbers of nursing and care staff supported by catering, domestic, laundry and maintenance personnel. The staff group is fairly static. There have been no staff vacancies since the last inspection. An additional bank carer has been recruited for nights. Staff training has been good and provided in both statutory and non-stututory areas. Since the last inspection there has been training in Infection Control, Nutrition, Fire Marshall Training, Food Hygiene and 7 staff are enrolled for a 12 week Dementia Training course (distance learning). The number of care staff with NVQ training meets the required 50 level. The cook has completed a Safer Food, Better Business course recommended on a recent visit by the Environmental Health Officer. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 22 All staff have received moving and handling training and updates. The home has an approved trainer for this purpose. Techniques observed during the inspection complied with current techniques and good practice. Two staff files were sampled and contained all documents required under Schedule 2 of the Regulations, the only exception being proof of qualification for one person who has been employed for 2 years but copy of qualification (NVQ) not produced as requested. Training records are available and the Manager intends to produce a training matrix easily identifying training undertaken and also training needs of all staff. Staff meetings are held regularly. Minutes of the last meeting dated 22.5.07 were seen – 19 matter raised, mainly by staff - were discussed and actioned. The home intend a more active involvement of staff in future quality assurance surveys. Application is being made to complete the Investors in People award. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 23 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. The home is well run and managed. The Manager takes a positive lead in the home and the presence of the owner allow direct access to both by residents. Staff are committed and well trained. The home is run in the best interests of residents. The health & safety of residents only compromised by the presence of COSHH items in some area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is a qualified nurse and has considerable experience in providing a service to older people. He is about to finalise the Registered Managers Award at a local college. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 24 The owner has a presence in the home most days and he has also completed the Registered Managers Award. Manager and Provider seem to work well in this home. The Manager takes a positive hands-on lead and role in this small nursing home. Residents have direct access to both. The atmosphere in the home is relaxed and good relationships and engagement observed between all staff, residents and visitors. Staff are professional and attentive to residents requests and needs. Residents finances were not inspected on this visit. Fire records were not seen on this visit. Previous requirements have been made to provide self-closing devices where fire doors have been propped open. There was no evidence of that on this inspection and additional self-closing devices have been provided. A requirement is made that bleach must be securely stored and not left in areas accessible by residents. This is vital to their safety. Westcroft Nursing Home DS0000026970.V338973.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 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 17 3 18 3 2 3 2 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 2 Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 4(1)(2) Requirement The Statement of Purpose/Service Users Guide must be updated to reflect the current service and facilities offered by the home. Bleach and other COSHH items must be securely stored to ensure safety of residents. Timescale for action 14/07/07 2 OP38 13(4) 13/06/07 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 OP19 OP19 Good Practice Recommendations Improve hygiene/presentation in toilet areas and ensure privacy. Improve personalisation of some bedrooms. Westcroft Nursing Home DS0000026970.V338973.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Local Office Commission for Social Care Inspection Dyson Court Staffordshire Technology Park Beaconside STAFFORD, ST18 0ES 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 Westcroft Nursing Home DS0000026970.V338973.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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