Inspection on 27/06/07 for Westfield Care Home

This inspection was carried out on 27th 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.

Other inspections for this house

Westfield Care Home 30/05/08

Westfield Care Home 13/06/06

Westfield Care Home 29/11/05

Westfield Care Home 22/08/05

Westfield Care Home 14/02/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westfield Care Home Devon Drive Mansfield Nottinghamshire NG19 6SQ Lead Inspector Jayne Hilton Key Unannounced Inspection 27th June 2007 07:45 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 Westfield Care Home DS0000008773.V340710.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. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield Care Home Address Devon Drive Mansfield Nottinghamshire NG19 6SQ 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) 01623 427846 01623 429874 lantraz@btconnect.com Lantraz Co. Limited Mr Ahmad Ally Toorabally Care Home 45 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (37) of places Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 37 Residents shall fall within registration category OP. 8 Residents shall fall within registration category DE Date of last inspection 13th June 2006 Brief Description of the Service: Westfield Care home provided 45 bedrooms of which 11 are en-suite, providing long term, short term and respite care for older persons. Eight beds are reserved for service users with dementia needs. Situated on Devon Drive in Mansfield, the home was purpose built in 1985. The home has 3 lounges on the ground floor and three on the first floor, which includes a lounge for those service users who wish to smoke. There is a call alarm system throughout, with grab rails and assisted bathing facilities. There is a spacious dining room. Access to the first floor is by means of a lift. Information on fees was provided on 9th May 2007 as £290-£334. Hairdressing, Chiropody and newspapers are charged for as extra. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 7 daytime hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting four residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Some of the people who live at this home have a limited ability to understand and communicate. Therefore some judgements in this report are from observation of staff and resident interactions Three members of staff and one relative were spoken to as part of this inspection. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Six questionnaires from service users and relatives were returned prior to the inspection. All were very positive in their comments. Relatives and service users highly praised the providers and staff team Relatives interviewed said they were given a brochure about the home, but had not seen an inspection report. The manager said this is available in the office on request. He was told he must be more proactive in making the last report and the Summary available to all residents and relatives so they are aware of the outcome of the inspections, which have been done. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The bathroom flooring has been repaired. Appropriate chairs are now in place for use in the bathrooms. The detail and records of service users has been improved, including healthcare. Service users are now informed in writing that the home can meet their specific needs. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 7 Staff are now provided with a copy of the General Social Care Councils Code of Conduct. Recruitment practices are improved. 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. The summary of this inspection report can be made available in other formats on request. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users generally have the information they need and an assessment is carried out, prior to them moving to the home and they know the home will meet their needs. However the provider should be more pro-active in providing information about how to access inspection reports on the home. The home does not provide an intermediate care service EVIDENCE: A statement of purpose was seen in the home and service user guides are displayed in each bedroom, which inform service users of their terms and conditions of residence. Within the assessment and care planning system there is a section included to obtain information about the service users cultural, spiritual and religious Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 10 needs but this should be expanded in relation to incorporating equality and diversity needs overall and where service users needs are discussed with relatives the detail should be recorded. There was evidence seen that relatives are involved in the assessment process, signatures of both the service user or their representative had been obtained in agreement, on most occasions. Extended community Care assessments were also examined and care plans that were devised appeared generally to derive from the assessed needs of the service user. Staff said they ensure they are aware of any new service users needs to assist them to settle into their new surroundings. The inspection report is kept in the office but is available on request. The provider stated that many visitors have requested to view the report. Relatives and service users spoken with were not aware of the inspection reports and therefore the provider needs to be proactive in informing all parties how they can access a copy of the inspection report including from the Internet. One service user had been admitted without a clear definition of their primary need and an outdated Community Care Assessment, discussions were being held by the Provider and the person’s Social Worker to establish this. The provider agreed to update the Commission for Social Care Inspection as to the outcome of the discussions. A relative said “A homely atmosphere is created, management and staff are closely aware of individual needs of residents A very caring attitude is displayed. As far as I’m aware individual needs are met”. A review of the registration certificate was undertaken and a recommendation to change the registration category to include that all of the beds may be used for people with Dementia. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 9 and 10Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ personal and health needs are set out in a care plan and service users needs are met and their privacy and dignity respected. However some areas for medication management require improvement to ensure any risk to service users health is minimised. EVIDENCE: Care Plans and risk assessments were noted to be detailed and up to date. Service users and relatives reported that the health care needs of service users were well met. A relative commented “ They recently brought in an action plan to safeguard mum from a series of falls she had experienced, this was done with careful consideration and respect for mums needs and I was kept fully informed of the problem” Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 12 Where there is a history of falls this is well monitored and the provider is auditing accidents. Service users and relatives spoken with confirmed that staff speak respectfully to them and maintain their privacy and dignity. Observation of practice on the day of the inspection confirmed this practice. A relative said “ They promote a friendly and supportive atmosphere for the residents as for my wife I cannot fault the care she receives from all members of staff I think the loving atmosphere in very important to people in care Westfield is a wonderful example of this” Another said “Very good care is taken, outside help is called to deal with medical conditions”. Parts of the system in place for the management of medication may place service users at risk and requirements are set in relation to these. A staff member was observed to handle medication with her fingers and place the medication into the service users mouth. The staff member continued to support other service users in the dining room without washing her hands. This practice is unhygienic and places service users at risk from cross contamination. Temazepam was not stored under Controlled Drugs requirements in a separate cabinet. The provider reported that the Community Pharmacist was now dispensing the drug in the blister packs. The provider must make the appropriate arrangements to ensure Temazepam is stored as required by regulation and it is recommended that their balance be recorded in a controlled drug register. Where prescriptions need to be handwritten onto the medication administration chart two competent authorised people need to sign that the entry has been checked as correct and that the entry contains the full prescribing details. One person had been prescribed Fortisip supplements twice a day but only one had been signed for on two days of the chart. No explanation was provided for this. Several gaps were identified for one person for two of their prescription items of medication. The provider was able to explain that an error had occurred by the medical practice and pharmacist and provided evidence for this. However where there are reasons for gaps in administration records this should be recorded on the rear of the medication record chart and cross referenced within the care plan. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 13 Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home generally matches their expectations and preferences and they can maintain contact with family/friends and representatives. EVIDENCE: The provider/manager reported that they would like to improve the quality and provision of activities in the home and had attempted to employ an activities co-ordinator without much success. There was evidence that activities such as board games, trips out, bingo and jigsaws are being provided three to four times a week and that service users were happy with what was provided. Church ministers visit the home and some service users are assisted to attend religious festivals/events, as they require. A relative said “the appointment of an activities co-ordinator would be very welcomed I know there has been difficulties with pervious applicants who were Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 15 in the post but we do see an urgent need for a suitably qualified person who could enhance and improve the quality of life for residents”. There was a lack of innovation and ideas for stimulation of service users, particularly those service users with dementia. Some ideas were discussed by the inspector to engender some innovation. It may also be helpful for the Providers to join NAPA - the National Association for Activities for Older People (a registered charity) its not expensive, but very effective in helping to improve the activities provided. Visitors said they were always made welcome and can visit at any time and that privacy is respected. Overall there was a good acknowledgement and understanding of equality and diversity in the service. In addition there is a multi cultural staff team and an equality policy in place. There is also a policy in place on promoting, rights, sexuality and relationships. A four weekly menu is provided which is varied and offers choice. Observations and records viewed on the day of inspection confirmed what service users and staff said about choices they make. Both service users and relatives said the food was lovely and that drinks are provided frequently and on request day and night. A relative said “I know mother is given choices re meals and drinks and is a safe environment for her. Her wishes as far a she is able to express them are fully respected but mostly she is following the daily routine of the home” Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are encouraged to make complaints if they are not happy with the service provided. Appropriate systems are in place to protect service users from abuse, neglect and self–harm. EVIDENCE: A complaint procedure was displayed. A copy of the complaint procedure is also available in the service user guide posted in service users rooms. Service users reported that they felt confident to make a complaint, and would speak with the management if necessary. Although those spoken with said they had never had to make a complaint, they felt confident any concerns would be dealt with appropriately. Five complaints were recorded in the home’s complaint records since the last inspection. Three of these had been notified to the Commission for Social Care Inspection and referred and investigated under the safeguarding adults protocols. No further action is to be taken from the referrals, but some good practice recommendations were made in the outcome, which the provider has taken action on. Two complaints included issues about manual handling practices of staff, wet clothing being left in a wardrobe and a hearing aid not being used. The Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 17 provider has taken appropriate action in responding to the complaints made and all were fully documented. Records and Staff confirmed that training in safeguarding adults is provided and most staff has undertaken training in challenging behaviour. Staff spoken with were knowledgeable about what constitutes abusive practice and reporting protocols. Observations made on the day of the inspection indicated a person presenting some challenging behaviour; there was a care plan in place for of how staff must deal with this in a consistent way. A staff member spoken with explained how she would deal with situations but did not refer to following guidance in the care plan. Neither had the staff member received training in challenging behaviour. [The staff member however had only been in employment at the home a few weeks] Records showed other staff had received training in challenging behaviour. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortable and well-maintained environment. EVIDENCE: The purpose built environment was homely and cleaned to a high standard. Furniture, carpeting and decoration was all to a high standard. The home is spacious and well laid out, with ample lounge facilities for those that wish to have quiet time. Maintenance of communal areas is good. A number of bedrooms were examined and all were well equipped, clean and fresh smelling. All were well personalised. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 19 Door locks are provided and lockable secure facilities. The laundry area was tidy and appropriate procedures were in place to meet the needs of the service. Gloves were observed around the home. Policies are in place for infection control and staff undertakes training in the topic. The Environmental Health Officer visited the home in March 2007 and made several recommendations in relation to the kitchen and to further improve food safety practices. There were no issues identified at this inspection and the provider reported that all of the recommendations had been actioned. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets service users needs and staff are trained to a satisfactory level. Recruitment practices are robust and ensure service users are protected from harm. EVIDENCE: There were twenty-seven service users in residence on the day of the inspection and staffing levels were assessed as appropriate to meet the needs of service users residing in the home. Relative’s comments include the following: “The home does everything well, entirely satisfied with all aspects. Could improve by retaining staff longer.” Three personal staff files were examined in relation to recruitment. Recruitment practices were assessed as fully satisfactory and all files had the necessary documentation required by law. The provider reported in the pre inspection questionnaire that 50 of staff has attained National Vocational Qualifications at level 2 or above and most staff holds first aid certificates. Staff confirmed alongside evidence in staff files that inductions are provided. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 21 Evidence was provided that staff receive a good level of training. Manual handling training, fire safety training, food hygiene, dementia Care, Continence promotion, challenging behaviour, protection of Vulnerable adults and Infection Control. Staff spoken with confirmed they had not undertaken training in health and safety. The provider had booked this for March 2007 but the training facilitator had cancelled the training. Evidence was seen that the training had been rebooked and planned for July 2007. It is recommended that staff undertake training in equality and diversity. Staff spoken with confirmed they had been issued with a copy of the GSCC [General Social Care Councils Code of Conduct] booklet. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users however some staff practices does not fully ensure the health safety and welfare of service users is promoted and protected. EVIDENCE: The registration for the manager of the home currently named Mr AA Toorabally. Mrs Toorabally has been helping out at the home, but is not a registered manager for this service. Comments made by service users, relatives and staff indicate the arrangement of Mrs Toorabally being included on the rota, may cause some confusion for staff and visitors and therefore appropriate communication must be shared with all concerned. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 23 A relative commented, “An appointment of a manager would be supportive and relieve the owners of the home some of the day to day burdens incurred in running the home” It is therefore recommended that the provider consider making an application for Mrs Toorabally to undergo the process to be registered with the Commission in respect of the amount of her time spent at the home. The Registered Provider undertakes visits as required by regulation and a service user survey has been carried out. Responses were viewed from January 2007.The Provider/manager is advised to extend surveys to visiting professionals and to focus the service user surveys to particular topics and then to feedback the results and any action taken as a result of comments made. There was evidence that staff supervision was in place and that the provider /manager is working to achieve six sessions a year for each member of staff. It was established that the records of deaths and the notifications received by the commission did not correlate. The provider agreed to provide copies of the notifications not sent. A fire risk assessment is now in place. Staff were observed to have left a trolley stocked with cleaning materials in an unlocked hairdressing room whilst they took a break. This left service users vulnerable should they wander into the room. All substances hazardous to health must be stored in a locked cupboard when not being used or fully supervised. The provider stated that this was not acceptable practice in the home and would take necessary action to ensure this practice would not be repeated. A sample of service users financial records were examined and found to be on the whole satisfactory. Valuables kept on behalf of service users are receipted for as written in the policy. It is however recommended that the system in place for receipting of hairdressing be improved as discussed at the time of the inspection. This will ensure service users are fully protected. Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 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 X 18 3 3 X X X X X X 3 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 X 3 X 2 3 2 2 Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 [2] Requirement The management of medication must improve as follows: The Medication Administration Record must be fully completed; This is to ensure that residents get their medication as prescribed by their Doctor. Timescale for action 27/08/07 2 OP9 13 [2] Controlled drugs (or those to be treated as Controlled Drugs) need to be stored securely. To ensure that medication is being administered safely and according to the residents’ prescription. Hygiene practices must be observed/maintained when administering medication. To ensure that medication is being administered safely and residents are not placed at risk of cross infection. 27/08/07 3 OP9 13 [2] 27/08/07 Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 26 4 OP38 13 [4] Ensure all substances hazardous to health are stored safely and not left accessible to service users as this may compromise their health and safety. 27/08/07 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 3 4 Refer to Standard OP1 OP3 OP30 OP31 Good Practice Recommendations Ensure information is available to all which informs everyone how he or she can access a copy of the inspection report. Expand on equality and diversity within the assessment documentation and ensure details of exploration of cultural needs is recorded such as skin care, dietary needs. Provide training for staff in Equality and Diversity. Consider making an application for Mrs Toorabally to undergo the process to be registered with the Commission in respect of the amount of her time spent at the home. Further develop the policy for service users financial accounts. Provide the Commission for Social Care Inspection copies of the Regulation 37 notifications that are not recorded as received as discussed. 5. 6 OP35 OP37 Westfield Care Home DS0000008773.V340710.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westfield Care Home DS0000008773.V340710.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!