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Inspection on 22/06/05 for Westcroft Nursing Home

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

This inspection was carried out on 22nd June 2005.

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

Small home providing a highly personal level of care with close professional, relaxed relationships between residents and staff. Individuality and preferred lifestyles are well catered for. Activities in the home fit the needs and demands of residents. Good hands-on care provided by all staff including the Manager.

What has improved since the last inspection?

There have been additions to policies/procedures as required. Residents are now checked hourly not 2 hourly throughout the night, although more detailed recording of checks is recommended. All residents, including those self-funding now have a formal review after the initial 6 week trial period. The home will no longer admit funded residents without a Care Management Assessment.

What the care home could do better:

Several omissions were identified in relation to health care matters. Residents should all be weighed monthly or weekly. Pressure area management must be recorded as prescribed in professional practice. The audible alarm to the nurse call system must be extended immediately to ensure it is heard by staff in all parts of the home. Residents are at risk if this is not done. Review of cleaning routines and some maintenance is required in the kitchen area. Privacy locks on toilet areas must be operative. Paving flags on the approach to the garden area must be made safe immediately. Corridors must be kept free of obstruction and combustible materials in the interests of fire safety. These should be routinely checked. Rubbish removal from the garden area would greatly improve its appearance. The refurbishment programme should be continued.

CARE HOMES FOR OLDER PEOPLE Westcroft Nursing Home 5 Harding Road Hanley Stoke on trent Staffordshire ST1 3BQ Lead Inspector Peter Dawson Unannounced Wed 22 June 2005 09.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pradeep Arvind Patel Mr Devdutt Meethoo Care Home 27 6 6 27 3 Category(ies) of DE (E) registration, with number MD(E) of places OP PD Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 February 2005 Brief Description of the Service: Westcroft 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 single and 5 shared bedrooms 18 having en-suite facilities. There are 2 bathrooms (one is assisted) and a 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. 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, 3 of whom may have a physical disability, 6 a mental disorder and 6 may require dementia care. The home is staffed by nurses at all times and supported by care assistants. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were 27 people in residence at the time of this unannounced inspection; this included 3 people who were in hospital receiving treatment for respiratory conditions. There have been 2 new admissions since the last inspection, both residents were seen and their care plans tracked. Some aspects of health care recording require improvements. A new MDS system of medication has been successfully introduced and staff feel provides a safe system. The 96th birthday of a resident was being celebrated with cake and special tea. This is done for all residents. All residents are escorted to hospital regardless of the time of day or night, or availability of relatives. The upgrading programme needs to be recommenced. Residents spoke highly of staff care, attitudes and commitment. Friendly, positive, supportive and caring exchanges were observed between residents and staff and humour appropriately interspersed in conversations. There is an excellent programme of activities provided many on a 1:1 personal basis for residents with high dependency. What the service does well: What has improved since the last inspection? There have been additions to policies/procedures as required. Residents are now checked hourly not 2 hourly throughout the night, although more detailed recording of checks is recommended. All residents, including those self-funding now have a formal review after the initial 6 week trial period. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 6 The home will no longer admit funded residents without a Care Management Assessment. What they could do better: 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 Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1 - 5 Prospective residents were introduced to the home prior to admission and information available to make and informed choice. Assessments are carried out as required. A Care Management assessment had not been provided relating to an earlier admission and the home will not allow that to happen in future. EVIDENCE: There is a statement of purpose and service users guide available in the reception area of the home for use by residents and visitors. The document accurately reflects the aims and objectives and level of service provided by the home. Sponsored residents have contract provided by local authorities and self funding residents a satisfactory statement of terms and conditions provided by the home. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 9 Care management assessments are provided for funded residents. The Manager completes an assessment prior to admission as defined in standard 3.3. for all prospective residents. At the time of the last inspection a Care Management assessment had not been provided for a resident who had been in the home for 3 months, a requirement was made but approaches subsequently made have not resulted in provision of that assessment. The matter is now academic, given that the person has been in residence for 7 months. The home will not admit future funded residents without a Care Management Assessment being provided prior to admission. Two new residents have been admitted to the home since the last inspection. They were seen and spoken to and records inspected. Appropriate steps had been taken to ensure assessments and introductions to the home prior to admission where that was possible. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7 - 10 There was good information in many care plans but some deficiencies found in aspects of health care recording viz: No fluid balance chart. No recording of pressure area management. Residents were not weighed regularly. In contrast high standards of care were seen to be provided for some highly dependent residents. Privacy locks on toilet doors require a permanent solution None of the 4 standards for Health and Personal Care were found to be fully met. Improvements could be made in these areas. EVIDENCE: Service user plans were sampled for recently admitted residents. Some deficiencies were identified in relation to recording of health care matters. A resident admitted with pressure area graded 2.2. (Sterling) had been treated appropriately with wound care dressings etc. Documentation did not provide information on the treatment regime and progress. This must be done. In relation to the same resident the care plan had identified the need to establish a fluid balance chart but this had not been done. It was found that there was no required consistent weighing of all residents. It is a requirement of this report that all residents must be weighed monthly and if there are concerns Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 11 about weight loss, those residents must be weighed weekly to allow close monitoring of their condition. There were good examples of complex health care needs being met. Residents are quite highly dependent in this home. Ten are double incontinent and ten also required to be hoisted with 2 staff present. Several require virtual total care for personal needs due to physical conditions and some with advanced stages of dementia. Care in these instances was observed to be provided in a sensitive and caring way and there were undoubted good professional standards of care in evidence. The medication system has been changed since the last inspection to the Monitored Dose System (Boots blisterpacks) from bottle to person system. Staff have adjusted well to this and feel it is a safe system. A good service is reports from the Pharmacy and there has been training and checks upon the new system. None of the current resident group self-medicate. Inspection of the medication and MAR sheets indicated only that a clarification was required in relation to medication which may not be PRN as stated on the MAR sheet, this will be checked with the pharmacy. Eye/ear drops are dated when opened and kept in a fridge as required. There were many creams which had not been dated when opened, although prescribed 1 year ago. It is good practice to date creams when opened, the accepted practice being to dispose of them after 3 months. This may a little rigid for some creams but indication are that some may have been used for a considerable time, dating will clarify. Following the last report all residents have been checked on an hourly basis throughout the night, recordings made of checks of bedguards but not record of resident activity throughout the night. It is strongly recommended that night staff record the status and activity of residents seen and checked throughout the night e.g. awake/asleep, toileted, restless, out of bed, drinks given, time spent, staff inputs etc. Residents spoken to said they were treated with respect by staff in all scenarios, particularly in the area of personal care. On the last inspection the 2 main toileting areas near to the communal areas were found to have privacy locks which were not operative, they were made operative on the inspection day. However the same 2 toilets on this inspection did not have privacy locks which could be used and this must be addressed in the interests of resident’s privacy. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12-15 There is tangible evidence of choice of lifestyles. The activities programme is excellent, caters for all and is well recorded. Family contacts are promoted; visitors see to be warmly received. Good meal provision is reported, the dining area extensively used for socialisation purposes also. EVIDENCE: There was evidence of flexibility of routines and chosen lifestyles. Arriving at 9 a.m. it was found that some residents had risen and had breakfast and others had not. Two residents had ordered cooked breakfast in their bedrooms. A 99 year old resident admitted some months ago with low dependency needs and total capacity was continuing to access all parts of the home as she wished, including the garden area. She spent time in her own room, the lounge areas and visited and entertained other residents in their respective bedrooms. An excellent example of chosen lifestyle. Dependency levels are generally high which dictate the choices which may sometimes be limited due to high physical and mental health needs. There is an excellent activities programme in the home run by 2 carers with specific time allocation for this purpose. Activities are provided on a one-to-one basis for many residents with limited concentration spans etc, and some small group activities provided both inside and outside the home. There are regular Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 13 residents meetings where the wishes, preferences and views of residents are sought in relation to activities. These are acted upon and all activities well recorded. A resident is again going on holiday escorted by the Manager to Blackpool for 4 days, this is an annual event which is very important to the resident. Clergy attend the home on a regular basis providing a service to all. Relatives are welcomed into the home and encouraged to take residents out where possible. It was an exceptionally hot day on the day of this unannounced inspection. External doors from conservatory and the lounge area were open due to the heat. It was disappointing to find that none of the residents were out in the shade overlooking the small but pleasant garden area. The area is well maintained and quite peaceful, if somewhat marred by the collection of furniture and rubbish in one corner which needs immediate removed. Many residents who are quite dependent spend time in the inner lounge area and in the opinion of the inspector would greatly benefit from a change of scenery, in the peaceful garden area. This certainly applies to several people with fairly advanced dementia conditions. Food provision is reported by residents to be good and satisfactory. Discussions with catering staff indicated choice of cooked breakfast, hot meal choices at lunch time, hot alternative at tea time and drinks and snacks available 24 as required. The mid day meal continues to be provided on a staggered basis with 2 sittings and resulting in a more relaxed period in the day when the main meal is served. This allows staff time to feed several residents without the pressure to feed all simultaneously. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 - 18 Standards relating to complaints and protection were found to be met. EVIDENCE: There is a complaints procedure covering all required aspects of Regulation 22. A copy of is posted in the home for residents and visitors. No complaints have been received by the home or the Commission since the last inspection. There is a policy/procedure relating to reporting abuse which is known to staff. Information includes the various definitions of abuse. There is a copy of the vulnerable adults procedures in the home. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19-26 Action is required to ensure safety for residents in the garden area as stated above. The nurse call system cannot be heard in all parts of the home and this is urgently required. A previous requirement has not been actioned. Further upgrading of the home is required as previously planned. EVIDENCE: There has been a programme of redecoration and replacement since the home was purchased 2 years ago. Provision addressing a previous period of underinvestment into the home. Since the last inspection there is no evidence of the programme continuing. Some areas do need recarpeting and furniture in bedroom areas particularly needs replacement. At the time of this inspection the home awaited the installation of a new central heating boiler. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 16 There have been vast improvements to the kitchen area following an outbreak of infection. On this visit it was clear that well defined stricter cleaning routines were required in the kitchen area, an example being of build-up of food deposits in the woodwork surrounding the serving area. Some areas of the kitchen also looked tired and require repainting. The flooring has been repaired several times but there are still gaps in the vinyl covering which would allow build up of food deposits. These matters need to be addressed. On the last inspection it became clear that the call system could not be heard in several parts of the building. There is only one place where there is an audible alarm. An immediate requirement was made to extend the audible system to include all parts of the home. This has not been done. The Manager reported contractors had been contacted but not able to commence work until September. This is not acceptable and it is a further urgent immediate requirement of this report that the call system must be audible in all parts of the home to ensure resident safety and to respond swiftly to residents needs. The garden area is small but has a lawned area with trees which is attractive and a patio area which has been improved. These positive facilities are negated by the accumulation of a considerable amount of discarded furniture and equipment over a period of time which has been left in this area. This must be swiftly removed. There are 18 en-suite bedrooms, 2 bathrooms (one assisted) and walk-in shower area. Additionally there are adequate toilet facilities located near to the communal areas. There is a shaft life providing access to both floors, there are grab rails and extensions to the toilets throughout the home. There are 2 hoists, one located on each floor and used to move 10 residents. Hot water controls are on baths but not on wash-hand basins. Weekly checks of hot water are randomly carried out but records were not seen on this visit. There are individual thermostatically controlled radiators in bedrooms and there are appropriate guards in place. Infection control standards were reviewed by the Health Protection Agency following a previous outbreak of infection. All matters were addressed and there was evidence of good infection control practices in the home at this time, with the exception of the kitchen area mentioned above. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 & 30. The numbers and skill mix of staff are maintained and are good. The home has a good record of staff training seen as a part of sustaining and improving competence. Standards inspected relating to staffing were met. EVIDENCE: The staffing levels remain as required at April 2002. This provides 686 staffing hours per week. This allows for 2 nurses and 4 care staff 8 – 2. 1 nurse and 3 care staff 2 – 10 although at certain periods there are 2 nurses and 4 carers from 2- 4pm. At nighttime there is 1 nurse and 2 care staff. There are adequate numbers of catering, laundry and domestic staff in support of care hour duties. The level of staffing is adequate for the dependency levels of the current resident group. There has been no use of agency staff since the last inspection. There are 16 care staff and 7 have completed NVQ training, a further member of staff is to commence in September. It is anticipated that the requirement of 50 of NVQ trained staff will soon be met. Staff files were not inspected on this visit. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 18 There has been a good programme of training at Westcroft over the past 2 years. There has been recent training in infection control, continence management and tissue viability (update). 2 Fire lectures are arranged for all staff in June/July and an updated dementia care course arranged for 27th July. Two new staff have been appointed since the last inspection and there are currently no staff vacancies. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 33 and 37 38 There is good leadership and management in the home. There are evidence close and warm relationships between staff and residents. Financial procedures were not inspected. Some areas of record keeping need improvement e.g. health care interventions, night records. Immediate attention required to safety issue in the garden area. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 20 EVIDENCE: The Registered Manager has the required experience to run the home and is a qualified nurse. He is to commence further training in September to obtain NVQ4/Registered Managers Award. The proprietor has a presence in the home most days and the Manager has the required authority and job description to allow him to manage the home effectively. The distinction in roles between Manager and Proprietor are known understood and practised. Observations indicate the Manager gives clear leadership to staff in the daily running of the home. There are regular staff meetings (minutes not seen on this visit), outcomes are circulated to all staff. All staff have received Codes of Practices published by GSCC. ; Financial procedures in the home were not inspected on this visit. The health, safety and welfare of residents are promoted in the home. Fire records were not seen on this visit. Two fire lectures had been arranged to cover all staff and notices posted for attention of all staff. It is recommended that mattresses stored in a corridor area adjoining a direct external fire exit from the first floor should be removed to allow free access in the event of fire. Risk assessments in relation to resident activity and the home are in place. Inspection of the garden area revealed 3 paving flags were unsafe in the area providing access to the garden and must be made safe/secure immediately. The Manager will arranged for this work to be carried out immediately by the maintenance person. All required notifications to the Commission had been made under regulation 37. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x x 2 2 Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 22 yes 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 22 Regulation 23(2) Requirement Alarm to call system must be audible in all parts of the home. PREVIOUS REQUIREMENT NOT MET Kitchen area must be kept clean and resonably decorated. Pressure area treatment and progress must must be appropriately recorded All residents must be weighed montly or weekly when there are concerns about weight loss Privacy locks on toilet door must be operative at all times REmove all rubbish from rear garden area Paving slabs in garden area must be made safe. Timescale for action Immediate 2. 3. 4. 5. 6. 7. 19 8.3. 8 10 19 38 23(2)(d) 12(1) 12(1) 12(4) 23(2) 13(4) Ongoing Ongoing Ongoing Ongoing Immediate Immediate 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 7 38 Good Practice Recommendations Hoursly night checks of residents to be recorded in more detail. Remove mattresses from first floor corridor area to allow E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 23 Westcroft Nursing Home complete access in the event of fire. Westcroft Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home E51 E09 S26970 Westcroft Nursing Home V234535 Stage 4.doc Version 1.30 Page 25 - 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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