Inspection on 12/09/05 for Westfield Lodge

This inspection was carried out on 12th September 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.

Other inspections for this house

Westfield Lodge 07/01/08

Westfield Lodge 22/08/06

Westfield Lodge 06/03/06

Westfield Lodge 22/06/04

Westfield Lodge 02/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Westfield Lodge 142 Norton Road Stourbridge West Midlands. DY8 2TA Lead Inspector Cathy Moore Unannounced 12 September 2005 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. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westfield Lodge Address 142 Norton Road Stourbridge West Midlands. DY8 2TA 01384 394912 01384 444540 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) Mrs Mary Dawes Miss Carron Hobbs Care Home 20 Category(ies) of DE Dementia (10) PD (E) Physical disability registration, with number over 65 (10) of places Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Nil Date of last inspection 11.01.05 Brief Description of the Service: Westfield Lodge has been in operation as a care home since 1985. The property was orginally a private detached family house to which extensions were built. The home now provides care to a maximum of twenty residents.Ten places are registered for people who have a physical disability, ten for people who have a diagnosis of dementia.The home does not provide nursing care. The home is located on the A451 main road from Stourbridge to Kidderminster in a residential area. The local town of Stourbridge can be accessed by public transport. A local park and public house with a restraurant are within walking distance. The home has a car park at the front of the premises and a mature and pleasant garden to the rear. Wheelchair users with the provision of ramps can access the garden. Westfield Lodge provides 14 single and 3 double bedrooms both on ground and first floors. Three rooms have en-suite toilets. There is a stair lift for access to the first floor. The home has 3 toilets and one assisted bath on the ground floor. On the first floor there is a toilet and a bathroom with a shower. There are two adjoining lounges on the ground floor and a dining room. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as the first of the homes two routine statutory inspections for this year. The inspection was carried out by one inspector during the hours of 07.40 and 15.10 hours. Two resident’ were chosen for case tracking purposes. This process involved the scrutiny of care plans, daily notes and risk assessments. Both residents’ were spoken to and their bedrooms viewed. The premises were randomly assessed which included the two communal lounges, dining room, the bathrooms on both floors, two toilets, the laundry and six bedrooms. Two staff files were assessed. Records pertaining to staff recruitment and training were perused as were service documents concerning hoisting and fire equipment. The manager was involved in the inspection. Two other staff were briefly spoken to. What the service does well: The registered person visits the home at least four times per week. Food provided at the home is of a good standard. Comments from residents’ about the food included “ The food is good, sensible but not dreary”. “ The food is beautiful we have a choice at meal times”. Positive comments from residents’ about the staff included “ The staff are beautiful, very kind and thoughtful”. “ The staff are pretty good”. One resident commented about the home in general ” The home is gorgeous, I’ve got no complaints, I’m happy, very happy”. The home is comfortable and homely. It is located in a sought after residential area. The majority of past requirements made have been met. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 2,3,4,5 Contracts and terms and conditions are not being completed as they should be. No resident moves into the home without having their needs assessed. However, there is little re-assessment or review processes once the admission is secured. The homes registration certificate does not accurately reflect the needs of residents’ accommodated. Prospective residents’ and their representatives have the opportunity to visit and assess the suitability of the home prior to admission. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 9 EVIDENCE: A contract or terms and conditions document was included on each residents’ file perused. These documents had not all been fully completed. The applicable room number, weekly fee, who is responsible for paying the fee or who is responsible for paying the fee were not detailed. There was evidence available to demonstrate that each prospective resident has their needs assessed before being offered a placement at the home. The registration certificate is not accurate. The dementia category as it is detailed applies to residents’ under 65 years of age, yet there is only one resident who meets this criteria. The physical disability category does not fully reflect the needs of the resident’ accommodated, many of whom appeared to fall within the category of old age not physical disability. One resident commented “ I came and looked around the home with my social worker before I was admitted”. One relative commented “ My sisters came and looked around the home before Mum was admitted”. There was no evidence of pre-admission/ introductory visits to the home. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 7,8,10. Care plans must be further developed and enhanced to ensure that these reflect each residents’ full needs. Further development is needed to ensure that each residents’ full health care needs are met. Residents’ are treated with dignity and their privacy is maintained. EVIDENCE: A care plan was in place on each of the residents’ files viewed. However, not all needs were fully reflected in the care a plan, for example, one resident has a history of wandering and requires assistance with personal care. These needs were not fully reflected in his care plan. Another would like to go out independently the staff however, are concerned about safety. This need is not reflected in his care plan. Risks identified in respect of tissue viability and nutrition lack mention in care plans. There was evidence that the care plans are being reviewed fairly regularly. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 11 There was little evidence that residents’ are at the present time receiving a full health care review from their doctor on at least an annual basis. The manager confirmed that this is in hand and this service will soon be provided. Residents’ are being seen on a regular basis by healthcare professionals, examples being district nurses, consultants who specialise in old age psychiatry and the chiropodist. There was less evidence to demonstrate that the dentist and optician are assessing residents’ on a regular basis. This may be due to the lack of specific health care visit recordings. The manager commented that these are generally written in the daily notes, rather than a health care visit record system. Weight monitoring processes are in place with records maintained of findings. Documentation is in place to monitor elimination, however this documentation is not always being completed consistently. There was evidence available to demonstrate that tissue viability and nutritional assessments are being carried out. These must be undertaken regularly where any risk is identified. Recording of personal care delivery has improved in terms of consistency. One relative confirmed that her mother’s personal care was attended to adequately. Staff were observed speaking to residents’ in a respectful manner. The preferred form of address had been established for each resident and recorded on their personal record. Appropriate locks are provided on bathroom, toilet and residents’ bedroom doors. A payphone is available in the ground floor office allowing residents’ to make private phone calls. A resident was taken to his bedroom to be treated by the district nurse to maintain his privacy and dignity. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 12,13,15 Further determination is needed in respect of residents’ preferred routines to ensure that the lifestyle experienced in the home matches their expectations and preferences. The home actively encourages visitors and for residents’ to maintain contact with family and friends. Residents’ are offered a varied diet. EVIDENCE: Rising and retiring times are recorded for some residents’ but not all. 15 residents’ were in the dining room at 07.50 hours. One resident commented “ We sometimes get up at 5am”. If residents’ choose to rise at this time this choice must be recorded on their care plans and raised at their next annual review. Another resident commented “ I get up when I want to, sometimes that is 12 noon”. There was inconsistency with the recordings of other preferred routines for example what time residents’ like to be bathed or showered. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 13 There was evidence of activity provision and resident participation in the activities provided. An external provider offers exercise therapy on alternative weeks a lady provides craft sessions on a regular basis. It was positive to see staff encouraging residents’ to sit in the garden in the sunshine on the afternoon of this inspection. At least two male residents’ are taken to the barbers on a regular basis. Visiting times are open and flexible. The terms and conditions document states “ Visitors are welcome at any time. Visitors can be provided with a meal at a reasonable price, drinks are free of charge”. The terms and conditions also informed visitors that they must sign the visitors book on entry and exist to the home to meet fire regulations. The majority of residents’ have visitors on a regular basis. They can use their bedrooms or a lounge area to receive their visitors. One visitor commented “ I can visit Mum at any time”. The home has a four week set menu. The menu details four meals per day breakfast, lunch, tea and supper. Food consumed on a daily basis by each resident is recorded. A list was available to inform staff which resident liked sugar in their drinks and which ones did not. A separate list was available detailing the milk preferences of each resident for example full fat, semiskimmed etc. The breakfast and lunch times were briefly observed. The manager was asked why residents’ were being given toast or a sandwich before their cereal at breakfast time. This issue was addressed instantly with staff. Lunch consisted of chicken pie, mixed vegetables and potatoes or sausage casserole. One resident had chosen to have sausages cooked on their own. Pudding offered was fruit crumble and custard or fresh fruit. One resident commented, “ On the whole the food is very good. It is always fresh”. Another commented,” The food is alright, but I’ve gone off food”. Staff were on hand to give assistance to residents’ who needed this. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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. The home has a complaints procedure a copy of which has been given to residents and relatives. Complaints information must be produced in a format which is appropriate to the residents’. EVIDENCE: The home has a complaints procedure which refers to the NCSC not CSCI when giving this organisations address and telephone number. The complaints procedure has different stages with an adequate time scale for responding to complaints. The complaints procedure has been produced in standard print. No large print or pictorial copy was available. The home or CSCI have not received any complaints a long time. There was evidence on residents’ files views to confirm that they or their relatives have been given a copy of the complaints procedure. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 19,20,24,25,26 Residents live in an environment which is safe. Redecorating work is required in many `areas of the home. Residents’ have access to safe and comfortable indoor and outdoor communal facilities. Residents’ bedrooms are comfortable but many require redecoration. Further exploration is required to ensure that water temperatures remain within the recommended range at all times and that lighting is adequate throughout the home. Audits are required to ensure `that bed linen is of a good quality at all times. Further development is required in respect of cleanliness of bedrooms and infection control processes. EVIDENCE: A random assessment of the premises was undertaken which included the garden, lounges, dining room, hallways and landings, the laundry, bathrooms 5 and first floor, toilets 6 and 8. The rear garden was seen to be pleasant with tables and chairs provided. A ramp enables easy access from the lounge to the garden. A number of residents’ were encouraged by staff to take advantage of the warm afternoon sunshine. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 16 Window frames seen throughout are made of UPVC bar the small window between the two lounges which is in need of redecoration or replacement. Lounge areas whilst comfortable would benefit from being repainted particularly the patio door areas and provided with new carpets. The carpet outside the kitchen door was seen to be inadequately clean and has obviously had a lot of wear and tear. Eight bedrooms were assessed during the inspection. Whilst these were seen to be comfortable redecoration of the walls and skirting boards in many of these is required. The flooring in room 10 is uneven by the skirting board, causing the new flooring to also be uneven. The overhead light in room 16 was not functioning correctly. The carpet of room 14 is stained by the threshold and has bleach stains in other places. There was no evidence to demonstrate that regular audits of bed linen are undertaken. There was documentary evidence available to demonstrate that residents’ have been offered a key to their bedroom doors and that they or their relatives had confirmed in writing that their bedrooms were satisfactory in terms of furniture provided. Residents’ spoken to said “ My bedroom is nice”. Another stated enthusiastically “ My bedroom is great, I really like it”. A relative commented about her mother’s bedroom “ She has all she needs in her bedroom, it is kept clean and tidy”. Radiators throughout the home are guarded. The lighting in communal areas satisfactory. Landings in general are provided with only one light. Assessment to determine LUX standards in these areas has not been carried out. Water temperatures are tested and recorded on a regular basis. Water temperatures were randomly tested during the tour of the premises whilst most were seen to be within the correct temperature range two were not. Bedroom 3’s hot water temperature read 21.3 OC and the water from the tap in the ground floor assisted bathroom 45.6 OC. Toilet floors have been replaced in the last year. The flooring by the bath in the first floor bathroom is carpet and could harbour bacteria. A commode pot was seen in the first floor bathroom bath. There were a number of extraneous items in this bathroom which included bedrails, a clothes airier and wheelchairs. Two sponges were observed in bathroom 5. A build up of dust on skirting boards was identified in a number of bedrooms assessed. Liquid soap and paper towels are provided in all communal bathrooms and toilets. Disposable gloves and aprons are available in different locations throughout the home. There have been no infectious diseases identified in the home. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 27,29,30 Confirmation of adequate staffing levels in respect of resident dependency levels and numbers must be made. The skill mix and competence of staff appears to be adequate. Greater scrutiny in respect of staff recruitment must be employed. Confirmation that staff induction and foundation programmes meets prescribed standards must be sought. EVIDENCE: The home is staffed as follows: A.M shift 3 care and one senior, plus the manager during the week. P.M shift 2 care and one senior. Night duty 2 waking staff. There is a cook available daily between 07.30 and 13.00 hours and one domestic. A discussion was held with the manager concerning staffing levels and whether they are adequate during evening times in terms of resident numbers and dependency levels. One resident tends to wander during this time and staff have to attend to other residents’ in addition to serving the tea and administering medications. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 18 Staff on duty appeared to be aware of the needs of the people in their care. One resident commented about the staff “ The staff are kind and thoughtful”. Two of the staff files were assessed. These contained a completed application form, two sources of identity and a health declaration. One lacked a recent professional reference and a valid enhanced disclosure/ POVA list check. Progress has been made in implementing induction and foundation training for new staff. There was evidence that new staff have commenced this programme. The manager is to compare the content of the homes course with the one prescribed by the National Minimum Standards for Older People. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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) 31,33,38 Residents’ live in a home, which is run and managed by a person who is fit to be in charge. Further developments are needed to ensure that the registered persons can demonstrate that the home is run in the best interests of the residents’. A number of areas require further attention/ remedial action to ensure that the safety of residents’. EVIDENCE: Since the last inspection the registered person has relinquished some of her managerial duties in respect of the home. She does however, maintain some responsibility and visits the home at least four times per week. A manager has been appointed and has been approved by the Commission as a fit person to manage the home. She has completed her Registered Managers Award and is awaiting the certificate. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 20 The registered persons have yet to implement a quality assurance/ quality monitoring system that meets all requirements detailed throughout standard 33. The Commission has not to date received any Regulation 26 visit reports from the registered person. It was observed during the tour of the premises that a number of doors are not fitting correctly into their rebates, these included doors 13,14,16,18 and 20. It was also identified that the floor hatch in the lounge caused an uneven surface. Random selection highlighted that portable electrical appliances had been checked in June 2005. There was however no check label on the lamp in room 14. One staff member was observed serving food an analysis of her training record revealed that she has not got a valid food hygiene certificate. It appeared that other training overall has been received by all established staff members. In May 2005 13 staff received moving and handling training, June 2005 12 staff received dementia awareness training. West Midlands Fire Service have carried out a recent inspection, a few recommendations remain yet to be met. A random assessment of servicing certificates was carried out which appeared satisfactory. The kitchen was not fully assessed during this inspection. It was however, identified that risk assessments have been completed to the satisfaction of Environmental Health. No dates were identified on hazard analysis data. The fly catcher risk assessment instructed that this equipment must be checked/cleaned weekly yet there was no evidence to demonstrate that this is being adhered to. Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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 x 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x x x 2 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x 2 x x x x 2 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 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 OP2 Regulation 5(1)(b) Requirement The registered person and manager must ensure that each residents contract/ terms and conditions document is signed and dated and that it includes: The applicable bedroom number. The applicable weekly fee. Who is responsible for paying the fees. Who is responsible if a breach occurs. The registered person and manager must ensure that a full recorded review is held in respect of each resident on an annual basis . A nominated person from the funding authority must be asked to review funded residents. The home must review private paying residents with family involvement where possible. A schedule of reviews must be produced. The registered person must apply to the CSCI to vary the Timescale for action 1.11.05 2. OP3 14(2)(a) 1.11.05 3. OP4 14(1)(a) 1.11.05 Page 23 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 4. OP5 14(1)(a) 5. OP7 15(1) 6. OP8 13(1)(b) 13(3) 7. OP8 12(1)(a) 13(1)(b) 8. OP8 12(1)(a) 9. OP8 12(1)(a) 13(2)( c) 10. OP12 12(2) homes certifcate of registration to ensure that it fully reflects the needs of the residents accommodated. The registered person and manager must ensure that a record is made of each residents introductory visit to the home. The registered person and manager must ensure that care plans fully reflect the needs, risks, choices and goals of each resident. Care plans must contain sufficient instruction to inform staff what must be done, how, when, how often and by whom. The registered person and manager must confirm with the infection control nurse that all required precautions are in place in respect of the one residents condition discussed during the inspection. The registered person and manager must ensure that all residents have regular access to dental and optician services.A system must be established to record these service visits whereby can be retreived quickly. The registered person and manager must ensure that where recording methods are implemented for example the elimination recording chart that these are completed consistently. The registered person and manager must ensure that where residents have been assessed as being at risk in respect of tissue viability or nutrition that these assessments are repeated regularly . The registered person and manager must ensure that the 1.10.05 1.10.05 25.09.05 1.10.05 25.09.05 1.10.05 1.10.05 Page 24 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 preferred rising time of those residents who wish to rise very early is included on their personal record. 11. OP12 12(2) The subject of rising times for residents who wish to rise very early must be raised during their next social work or annual review. The registered person and manager must ensure that: The complaints procedure is produced in a format appropriate to the residents. Reference to the NCSC in the complaints procedure is changed to CSCI. 13. OP19 23(2)(b) The registered person and manager must undertake an audit of the homes overall decorating needs. A programme of redecoration must be produced a copy of which must be forwarded complete with timescales to the CSCI. The programme must include : Replacement or redecoration of the small lounge window frame. The deep cleaning or replacement of lounge carpets. The replacement of the carpet near to the kitchen. The redecoration of lounges. The redecoration of bedrooms. 1.11.05 1.01.06 12. OP16 22(2) 22(7)(a). 1.11.05 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 25 14. OP24 13(4)(a) 16(2)(c ) The registered person and manager must ensure that; The flooring in bedroom 10 is made even. The new flooring in the ground floor bedroom identified during the inspection is stretched. That a documented audit of all bedroom carpets is undertaken to determine which ones require reoplacement. Timescales must be detailed where replacements are needed. In the interim period documented risk assessments must be carried out. The registered person and manager must ensure that a regular documented audit of bed linen in carried out and that bed linen is replaced as needed. The registered person and manager must ensure that in future the date that residents or their relatives sign to say that they are satisfied with the furniture in their bedrooms is entered on the documentation. The registered person and manager must ensure that the lighting in all rooms meets the specified LUX standards. The registered person must ensure that water temperatures throughout the home remain within the recommended range close to 43 OC. The registered person and manager must ensure that the wall light in bedroom 16 is mended. The registered person and manager must ensure; 12.10.05 15. OP24 16(2)( c) 1.10.05 16. OP24 16(2)( c) 1.10.05 17. OP25 23(2)(p) 1.11.05 18. OP25 13(4)(c ) 23(2)(p) 25.09.05 19. OP25 23(2)(p) 25.09.05 20. OP26 23(2)(d) 12.10.05 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 26 That skirting boards throughout the home to include bedrooms are adequatley cleaned at all times. A cleaning schedule must be produced and completed each time tasks are carried out. Assessment of current domestic hours must be carried out to determine if these are sufficient.The outcome of which must be forwarded to the CSCI. The registered person must continue with the refurbishment of the laundry. The registered person and manager must ensure that; No personal care items are stored in the bathroom an example being bath sponges. That all extraneous items are removed from the first floor bathroom.This also to include the hoist in the ground floor bathroom. The registered person and 25.09.05 manager must identify , manage and erradicate the source of odour in bedroom 14. The registered person and 12.09.05 manager must ensure that commode pots are not cleaned in the bath. The registered person and 12.09.05 manager must provide the CSCI with an up to date account of the dependancy levels of the residents determined by low, medium and high dependancy ratings and evidence throughout the month of September 2005 the numbers of care hours provided each week. Version 1.40 Page 27 21. 22. OP26 OP26 23(2)(j) 13(3) 1.12.05 25.09.05 23. OP26 23(2)(k) 24. OP26 23(2)(j) 25. OP27 18(1)(a) Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc 26. OP29 13(6) 19(2) The registered person and manager must ensure that no staff are allowed to commence employment unless a satisfactory CRB/POVA list check has been received. A copy of which must be available for inspection. An immediate requirement was issued to this effect during the inspection. The registered person must ensure that the staff member employed without a CRB/POVA list check is removed from care duties and is supervised by a named senior during her work at the home. An immediate requirement was issued to this effect during the inspection. The registered person and manager must ensure that a professional reference is obtained from each prospective staff members immediate last employer. The registered person and manager must compare the homes induction and foundation programme to ensure that it contains all elements included in the prescribed version. The registered person must carry out an unannounced Regulation 26 visit on a monthly basis and compile a written report of their findings a copy of which must be forwarded to the CSCI. The registered person and manager must ensure that the homes quailty assurance/ quality monitoring systems cover all required areas detailed throughout standard 33. 12.09.05 Immediate 27. OP29 13(6) 19(2) 12.09.05 Immediate 28. OP29 13(6) 19(2) 12.09.05 29. OP30 18(1)(a) 1.10.05 30. OP33 26(1)(3) (4)(5). 12.10.05 31. OP33 24(1)(2) (3) 1.11.05 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 28 32. OP38 13(3) 16(2)(j) 18(1)(a) Timescale of 1.1.05 not fully met. The registered person and manager must ensure that no staff are involved in food preperation or serve food unless they have a valid food hygeine certifcate. An immediate requirement was issued to this effect during the inspection. The registered person and manager must carry out a documented audit of all doors. Doors that do not shut correctly into their rebates must receive the required remedial work. ( This to include doors 13, 14, 16,18 and 20) Written evidence that this has been addressed must be forwarded to the CSCI. The registered person and manager must confirm that the lamp in bedroom 14 has been PAT tested. The registered person and manager must; Ensure that all hazard analysis data is dated when produced. Ensure that the weekly checks of the fly catcher are recorded. The registered person and manager must ensure that the hatch cover in the lounge is adequatley secured and is not a tripping hazard. The registered person and manager must ensure that all recommendations/ requirements made by West Midlands Fire service are addressed. 12.09.05 33. OP38 13(4)(a) 23(4) 30.09.05 34. OP38 13(4)(a) 1.10.05 35. OP38 16(2)(j) 30.09.05 36. OP38 13(4) 23.09.05 37. OP38 23(4) 1.11.05 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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 Westfield Lodge E55 S25040 Westfield Lodge V248810 120905 Stage 4.doc Version 1.40 Page 31 - 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!