Inspection on 22/08/06 for Westfield Lodge

This inspection was carried out on 22nd August 2006.

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 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 06/03/06

Westfield Lodge 12/09/05

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 Mrs Cathy Moore Unannounced Inspection 22nd August 2006 07.20 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 Lodge DS0000025040.V308271.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 Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield Lodge Address 142 Norton Road Stourbridge West Midlands DY8 2TA 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) 01384 394912 01384 444540 westfieldlodge@btconnect.com Mrs Mary Dawes Mr Dennis Dawes Miss Carron Hobbs Care Home 20 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (10) Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the 20 places registered the home can accommodate the following: DE(E) - 60 years and above - 1 service user PD(E) - 5 service users 06/03/06 Date of last inspection Brief Description of the Service: Westfield Lodge has been in operation as a care home since 1985. The property was originally a private detached family house to which extensions were built. The home now provides care to a maximum of twenty residents. Seven places are registered for people who have a diagnosis of dementia, three for people who have a mental disorder and ten for older people with no other needs. The home does not provide nursing care. Westfield Lodge 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 restaurant 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 which are located on ground and first floors. Three bedrooms 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. The fees for Westfield Lodge range from £343-£410 per week. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.20 and 15.50 hours. The inspection process assessed all key National Minimum Standards for older people. To aid the inspection process a pre-inspection questionnaire was forwarded to the home weeks before the inspection for completion along with resident questionnaires that residents and/or their relatives completed. At least 50 of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection three residents’ files to include their assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounge, dining room, five bedrooms, the laundry, kitchen, garden, bathrooms and toilets. Medication systems were also assessed and the lunchtime was indirectly observed. Seven residents, four staff and one relative were spoken to during the inspection. What the service does well: The registered provider is on site at least four times per week and has some involvement in the homes functioning and operation. The home is located in a pleasant residential area. It is comfortable and homely. The homes atmosphere was as during the previous inspection welcoming and positive. The home actively encourages visitors and for residents to maintain contact with family and friends. The meal provided was attractive and appetising. The manager continues to have a positive attitude and drive to improve the home and care to the residents’. She is motivated and shows great interest in her work and job role. The home has a low turnover of staff. Only one cleaner has left since the last inspection. A number of staff have been employed for some considerable time Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 6 providing stability and consistency of care to the residents’. The staff group continue to demonstrate a positive attitude towards their work. Staff have a good knowledge of the needs of the residents in their care. Positive comments were received from residents and relatives about the home in general and the staff and include the following; “ I think my mother receives excellent care in an environment which seems like home not an institution”. “ Mum is very happy here and so are we. Everything is o.k., no problems”. “ Very happy, well looked after. We are happy with the service”. “ The people are kind”. What has improved since the last inspection? What they could do better: Fine tuning is needed in a few areas examples being care plans and quality assurance. The purchasing of a medication trolley would increase safety and time efficiency. Morning rising times for residents needs further exploration and questioning to ensure that they meet their individual requirements as some comments were received as follows; “ They have to start early with someone 06.00 – 06.30, it is an effort sometimes when I would rather have a rest”. “I would rather stay in bed longer”. However ,one resident said; “ Time getting up does not bother me”. Activity provision needs further development and improvement. An additional staff member must be provided each afternoon shift. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 7 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 DS0000025040.V308271.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 Lodge DS0000025040.V308271.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 The overall judgement for this set of standards is good. Each service user has a written contract. No service user moves into the home without having their needs assessed. EVIDENCE: A terms and conditions document was available for one of the three residents’ whose records were assessed. Two of these residents’ were new to the home their terms and conditions document had been sent to their relatives for perusal and signing. Fourteen of the fifteen completed resident questionnaires received confirmed that they have been issued with a contract which is really good as this shows compliance with requirements- the remaining one did not answer the question. An assessment of need document was in place for each of the residents’ whose files were examined. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 10 It was positive to see that the last inspection report was on display in the front entrance hall. It is extremely pleasing that residents/relatives felt that they had been given enough information prior to their admission to enable them to make a decision about the suitability of the home. This confirmed by fifteen of fifteen completed resident questionnaires received. Westfield Lodge DS0000025040.V308271.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The overall judgement for this set of standards is good. Service users health and personal care needs are set out in a care plan. Service users health care needs are being met. The homes’ medication systems although require some ‘fine tuning’ are well organised . Service users feel that they are treated with respect . EVIDENCE: A care plan was on file for six residents whose records were checked. One care plan was in the process of being produced as the resident had not long been admitted to the home. Care plans in general were of a good standard detailing individual care instructions for each. The only shortfall identified was the review process which is being recorded on loose leaf papers that could easily be mislaid. It is extremely positive that residents have been made aware of their care plans this evidenced by their signatures. Additionally a record on each file read; ”We at Westfield Lodge would like to give you the opportunity to say whether you would like to keep your care plan in your possession and please state whether or not you a family member to have access to your care plan”. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 12 Record keeping confirming professional visits was very good. One resident had been seen by the dentist on 26.10.05 and 17.8.06, the chiropodist four times in the last 10 months and the optician on 10.1.06. Another resident had seen the nurse for a blood test and the psychiatrist. Records seen for other residents confirmed good access to health care professionals. Twelve of the fifteen completed resident questionnaires received confirmed that they always receive the medical support they need, Two usually and one did not comment. Three relatives commented that they were always informed if their mother was not well. There was evidence on all resident files viewed that they had been weighed on admission and regularly since then to enable their weight to be monitored. There was also evidence available to demonstrate that residents are checked regularly concerning nutritional assessment and tissue viability to enable then to detect concerns / well being. Generally, residents looked clean and well dressed. One female resident wore nail polish that had been applied for her by the staff, she seemed pleased with that. Staff were seen and heard discreetly encouraging those residents who needed prompting to use the toilet. Toilet and bathroom doors have good pictorial signage which helps service users know where the toilets are located. There were records of daily personal care delivery. It was noted however, that one residents fingers/finger nails were dirty. This was brought to the attention of the manager who said; “ I will deal with that and ensure that staff are aware to check the nails at least daily”. Medication systems have improved considerably since the last inspection. Inbetween the Commission pharmacist also carried out a medication audit. The home is now provided with pre-printed medication records from the dispensing pharmacist and has good records of medication coming into and going out of the home. It is extremely positive that the home has secured additional input from residents’ doctors and a health pharmacist to carry out regular medication reviews to ensure that all resident medication being prescribed is suitable. The only shortfalls identified were that care plans are not in operation or available for medication being prescribed as ‘ as needed’. That the home does not have a medication trolley to aid medication administration. The medications are stored in the pantry area which means that staff have to go to and fro through the kitchen which is not advisable and that the task is taking longer than it need. That black and white resident photos are attached to the medication records rather than colour ones which would make clear identification easier. The preferred form of address for each resident has been established and recorded. As has male residents views about being cared for by opposite gender staff. Staff observed during the inspection were polite and respectful to the residents in their care. Toilet and bathroom doors were seen to be shut when in use. One resident said; “ The staff are pleasant and polite”. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall judgement for this set of standards is good. Exploration and development is needed concerning the lifestyle expectations of each resident. The home very much encourages residents to maintain contact with family and friends. Residents are helped to exercise choice over their lives. Residents receive appealing meals. EVIDENCE: Evidence was available to demonstrate that activity provision is provided inhouse by the staff. One staff member said; “ We try and do things with them. Some afternoons we do manicures the residents like this, makes them feel pampered”. An activity schedule was available on the notice board in the main lounge. One day per week an external provider visits the home to carry out certain activities. The home has another external provider who encourages gentle exercises. The home is registered to provide care to seven residents who have dementia. Activity and stimulation is particularly important for them – as with all residents. Eight of the completed resident questionnaires received confirmed that activities are arranged by the home that they can take part in always, six usually and two sometimes. Whilst this feedback is positive the ‘usually’ and Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 14 ‘sometimes’ responses do need further exploration and action. It is required that 10 hours total, devoted activity provision a week is provided by a dedicated activities co-ordinator. Whilst it is positive that the preferred rising times of each resident has been determined and recorded on entering the home at 07.20 hours at least fourteen residents were up and dressed in the lounge. Comments received about this early rising from residents included the following; “ I can’t have a cup of tea in bed”. “ They have to start early with someone 06.00 – 06.30, it is an effort sometimes when I would rather have a rest”. “I would rather stay in bed longer”. One resident said; “ Time getting up does not bother me”. The home has open, flexible visiting times. The home encourages residents to maintain contact with family and friends. One visitor said; “ We can visit anytime we want and she comes out with us on a Saturday, Weather permitting”. Written materials relating to external advocacy and advisory bodies were available and on display in the home. Residents are encouraged and able to bring into the home with them their personal belongings. One residents bedroom seen was full of his personal belongings, a television, telephone, pictures and books. Planned menus were available to peruse. Menus are displayed on a daily basis detailing four meals breakfast, lunch, tea and supper. Service users are asked the day before what they would like the following day. It is clearly stated on the menu that residents can have a cooked breakfast on request. The kitchen was briefly assessed. Meat is delivered weekly and is used within the week to ensure that old stock is not held. Fresh fruit was available in the kitchen. Food stocks seen were varied and adequate. The main meal time of the day was briefly observed. It consisted of chicken nuggets, or egg and chips, baked beans or peas and bread and butter followed by fruit crumble or fruit and custard. The meal smelt appetising, was well presented with good sized portions. Staff were on hand to give assistance and encouragement to those residents’ who needed help. One female resident was given her lunch in a large dish to help her eat independently. The dining room is fairly small, but is a pleasant. The tables were nicely laid. To enhance healthy eating residents are offered oven chips rather than deep fried chips, whilst residents spoken to seemed happy with this one said; “ Don’t like oven chips, the rest of the meal was ok”. Other comments following the main meal were as follows;” It was lovely”. “ Lovely, very nice indeed”. “ I always enjoy the dinner”. It is positive that food likes and dislikes ( including milk preferences) are determined for each resident on admission to the home and that records are made following each meal of food consumed by each resident. Records are also made of each residents’ daily fluid intake. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The overall judgement for this set of standards is good. Complaints procedures are in place to enable residents to voice their dissatisfactions or concerns. Processes are in place aimed to protect service users from abuse. EVIDENCE: Westfield Lodge has a written complaints procedure which is available within the home. It has a 28 day deadline for responding to complaints. No complaints have been received by the home or the Commission for some time. Feedback from resident questionnaires suggest that the majority of residents/ relatives know how to make complaint and know who to speak to if they are unhappy. One concern was raised prior to the inspection by an unknown source claiming that on occasions when the visiting the home she saw; ‘ Evidence of excrement in the living areas and people left in wet clothes because staff were failing to toilet appropriately- this caused a small of urine through the home’. This concern was investigated as part of the inspection process. There was a slight odour in the entrance hall and the main lounge but nowhere else in the home. The manager confirmed that; “ At times residents do have accidents”. A requirement has been made for the management of the odour to be dealt with. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 16 The home is registered to provide care to residents’ who have dementia. The manager confirmed that there had been problems in that although residents’ are encouraged to use the toilet a number had been using the end of one corridor as a toilet. To manage this apart from regular toileting, easier to clean flooring has been fitted in these areas. It is positive that the home to aid orientation for residents to know where the toilets and bathrooms are, large coloured pictorial signage has been provided on toilet and bathroom doors. There was no evidence to suggest that staff are not toileting appropriately. The inspector sat in the lounge area and observed daily routines and saw that residents were encouraged to use the toilet. Residents clothing and chairs were observed for wetness or excrement when they stood; none was seen. The outcome of this investigation is yes, there may be problems at times with incontinence and there is a slight odour in the main hall way and lounge but there was no evidence at the time of the inspection that this is being caused by staff failing to toilet appropriately. Eleven of the fifteen completed resident questionnaires received confirmed that; ‘The home is always fresh and clean’ one answered; ‘usually’ to this question. Which is a high proportion in favour of the homes cleanliness and freshness. A further comment of;“ The home always smells nice” was received. These comments further confirm that; ‘there is not an odour throughout the home’. No allegations or incidents of abuse have been reported to the Commission concerning Westfield Lodge. The manager confirmed; “There have been no incidents or allegations of abuse and no staff misconducts”. The home has in place a number of policies and procedures aimed to protect vulnerable adults which require a minor addition to instruct staff to inform the Commission if anything untoward occurs. A number of staff have received abuse awareness training. Further training has been arranged for 18 October2006. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The overall judgement for this set of standards is adequate. The home is safe and reasonably maintained throughout. Its cleanliness and hygiene levels need a little attention. EVIDENCE: It is positive that the registered provider has an on-going refurbishment and redecoration plan. Since the last inspection some rooms and hallways have been fitted with laminate style flooring, one bedroom at least has been fitted with a new vanity unit and wardrobes. The home was randomly assessed to include the lounge areas, kitchen, laundry, toilets, bathrooms and five bedrooms. Generally, the home is adequately decorated throughout but may benefit from ‘brightening up’ here and there. The main lounge carpet has seen better days it is very faded by the patio door area. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 18 Toilets and bathrooms were found to be clean and provided with paper towels, liquid soap and disposable gloves. It is positive that ‘ Hand wash’ signs were displayed in all. The garage is utilised as the laundry area. This is a fairly big room with a deep grooved tile floor. The floor and sink on the day of the inspection were seen to be in need of a clean. There is no clear dedicated areas for the segregation of clean and dirty washing which would be better to prevent infection transmission. The laundry equipment was adequate. The home only has a cleaner five days per week – four hours per day who undertakes a dual cleaning/laundry role. This is not adequate as in terms of size the home is large. Cleaning and laundry duties at times when the cleaner is not on duty have to be undertaken by care staff which depletes care hours/time. As stated in the previous section a slight odour in the main hallway and lounge was detected which needs attention. Feedback from residents and relatives about the cleanliness of the home is positive; eleven of the fifteen completed resident questionnaires received confirmed that; ‘The home is always fresh and clean’ one answered; ‘usually’ to this question. Which is a high proportion in favour of the homes cleanliness and freshness. A further comment of: “ The home always smells nice” was received. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall judgement for this set of standards is adequate. Improvement is needed in the afternoons to increase staffing levels. Staff are adequately trained to do their jobs. Staff recruitment processes need some ‘fine tuning’. EVIDENCE: Three care staff are provided for all day time hours except for afternoon times. Two staff at this time is not adequate and must be increased to three, seven days per week. Staff observed and spoken to were committed to their job role and looking after the residents in their care. It is positive in that twelve of the fifteen completed resident questionnaires received confirmed that;’Staff always listen and act upon what they said’. Positive comments were received about the staff in general and included the following; “ All very helpful, friendly no problems”. “ Nothing too much trouble”. Friendly and caring”. “ Girls are nice”. The pre-inspection questionnaire confirmed that 70 of the staff team have attained N.V.Q level 2 or above which is very good. Only one staff member has been employed since the last inspection. Her file was assessed and it was confirmed that the required checks had been carried out. The only shortfall identified was that she had commenced employment before the home had received a full enhanced disclosure only a POVA first. The Commission had not been informed of this. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 20 As with the last inspection it was noted that there was no evidence of enhanced disclosures for visiting professionals and the hairdresser. It was pleasing that a file containing required documents is now in place for the selfemployed handyperson. There was evidence on file of in-house inductions and formal induction processes which is good. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall judgement for this set of standards is good. Service users live in a home which is run by a manager who has been assessed as being fit to be in charge. Completion of systems and policies is needed before it can be deemed that the home if fully being run in the best interests of the residents. The home does not ‘safe keep’ any money for residents. Staff are appropriately supervised. Health and safety requirements in the home are complied with. EVIDENCE: The manager has been approved by the Commission as a fit person to be in charge. She has attained NVQ level 4 and has recently completed her Registered Managers Award. It is pleasing that progress has been made in terms of quality monitoring and quality assurance processes with satisfaction surveys and audit processes Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 22 being used. The completion of the whole processes is expected in a month or two. The manager confirmed that the home does not hold money on site for any of the residents she explained that if hairdressing or other money is needed the registered provider pays then invoices the families. Evidence was available to demonstrate that staff are receiving formal one to one supervision sessions. This further confirmed by two staff spoken to. The kitchen was briefly assessed, it appeared to be clean. Generally food products are properly labelled and temperatures of fridges, freezers, cooked food and food on delivery are taken and recorded. The manager confirmed that Environmental Health were due to visit soon to assess recording keeping against the new records they have issued. The manager confirmed that she would raise with the Environmental Health officer the staff room where some staff smoke which is located off the kitchen as a past requirement has instructed. A random assessment of risk processes, fire safety checks and equipment servicing was undertaken, this was all found to be in order. Accident analysis is being carried out by the manager. The only shortfall identified was that falls where injuries have not been sustained are not being recorded in the accident book only in the day/night notes. This information may be lost and therefore not used in accident prevention strategies. There are gaps in staff training, for example not all night staff to date have received food hygiene training. However, the manager was able to evidence that she is continuing to secure training and was able to provide the following training dates; infection control was undertaken July 2006, health and safety training booked for September 2006 and fire training/ drills booked for November 2006. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 23 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 HOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 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 2 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 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 3 Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 17(2) Requirement The registered provider and manager must develop a system to ensure that care plan review documents are safely secured. The registered provider and manager must ensure that a care plan for each resident is produced in respect of their medication. This care plan must confirm all special instructions regarding their medication examples being; Timescale for action 22/09/06 2 OP9 13(2) 22/09/06 3 OP9 13(2) How ‘ when required ’ medication should be administered. The registered provider and 22/09/06 manager must ensure that each resident’ medication record has an up to date photograph of them attached. This must be clear and in colour. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 25 4 OP9 13(2) 13(3) 5 OP9 13(2) 6 OP12 12(2) The registered provider must provide a suitable medication trolley to ensure safety in transit and during administration and decrease the number of times the kitchen has to be accessed. The registered provider and manager must ensure that the medication error policy gives clear instruction that if a medication error were to occur the CSCI must be informed in adherence with Regulation 37. The registered provider and manager must ensure that; The preferred rising time of each resident is further explored. 01/11/06 22/09/06 25/09/06 7 OP12 16(2) (m)(n) 13(6) 8 OP18 9 OP26 13(3)18 (1)(a) Residents are asked each day if they would prefer to stay longer in bed. The registered provider and 22/11/06 manager must ensure that an activities co-ordinator is provided at least 10 hours per week. The registered provider and 22/09/06 manager must ensure that instruction is added to all protection policies so staff are informed that they must report to the CSCI ( e.g. missing persons policy, abuse policy etc). The registered provider and 22/09/06 manager must ensure that domestic / laundry staff are provided every day. When on holiday/sick the post must be covered. Timescale of 25/04/06 not met. Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 26 10 OP26 13(3) The registered provider and manager must ensure; That the laundry is adequately clean at all times. The sink in the laundry was not adequately clean. Timescale of 25/03/06 not fully met. The registered provider and manager must ensure that the odour in the main lounge is managed and eradicated. One remedy maybe to replace the carpet. The registered provider must increase care staffing levels in the afternoon from 2 to 3 ( 7 days per week) The registered person must ensure that all persons entering the home to provide personal care examples being; The hairdresser. Chiropodist. Dentist etc All have a valid CRB. Timescale of 01/04/06 not met. 22/09/06 11 OP26 16(2)(k) 01/10/06 12 OP27 18(1)(a) 22/09/06 13 OP29 13(6)19 (2) 22/09/06 14 OP29 19(1) 19(2) The registered provider and manager must where they have made the decision to employ staff on a POVA first before receiving their full CRB inform the CSCI of this and reasons why. Where only a POVA first is received before employment the following must be carried out; Risk assessment. Named supervisor per shift highlighted on the rota. 22/09/06 Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 27 15 OP33 24(1)(2) (3) The registered person and manager must ensure that the homes quality assurance/ quality monitoring systems cover all required areas detailed throughout standard 33. Requirement nearly met. 01/11/06 16 OP38 13(3)16 The registered person and (2)j18(1)a manager must ensure that; Night staff have not had this training so would not be able to prepare a snack in the night if requested by any of the 20 residents’. Timescale of 01/05/06 not fully met. 17(2) The registered provider and manager must ensure that all professionals entering the home to provide care examples being; The hairdresser. Dentist. Chiropodist etc. All have valid public liability insurance. The registered provider and manager must ensure that staff do not smoke in the room next to the kitchen. For further advice on this matter contact Environmental Healthfood safety section. The manager has contacted the above department who will be visiting the home in the next two months. 01/11/06 17 OP38 01/11/06 18 OP38 16(2)(j) 01/11/06 Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 28 19 OP38 13(4)( c) The registered provider and manager must ensure that all incidents and accidents (i.e. when residents are found on the floor) are recorded in the accident book. 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westfield Lodge DS0000025040.V308271.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands 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 DS0000025040.V308271.R01.S.doc Version 5.2 Page 30 - 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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