Inspection on 06/03/06 for Westfield Lodge

This inspection was carried out on 6th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 12/09/05

Westfield Lodge 22/06/04

Westfield Lodge 02/03/04

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Maple Lodge

Heathlands

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Breme

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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 6th March 2006 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 Lodge DS0000025040.V285085.R01.S.doc Version 5.1 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.V285085.R01.S.doc Version 5.1 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.V285085.R01.S.doc Version 5.1 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 12/09/05 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. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as the homes’ second routine inspection for this year. This inspection was carried out by one inspector between 07.45 and 13.15 hours. The inspection was conducted to focus on National Minimum Standards for Older People that were not assessed during the last inspection and previous requirements made. Two residents’ files were examined to include assessment of need, care plan, risk assessment and other documents. The premises were assessed in relation to progress made in respect of previous requirements. The kitchen and laundry were viewed as were bathrooms and toilets concerning infection control. Service records and maintenance of equipment were checked. The homes’ medication and medication systems were assessed. Five residents’ and two staff members were spoken to. The owner, manager and one deputy were all part involved in the inspection process. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the last report dated 12 September 2005. What the service does well: The registered provider visits the home at least four times per week and has considerable involvement in its operation and functioning .The manager has a positive attitude and drive to improve the home and care to the residents’. She is motivated and shows great interest to improving her performance. The home has a low turnover of staff. No staff have left since the last inspection. A number of staff have been employed by the home for some considerable time providing stability and consistency to the residents’. The staff group demonstrate a positive attitude towards their work. The owner and manager have identified that an increase in staff hours is needed and are advertising for an additional 20 hour care post. The homes atmosphere was warm, welcoming and positive. It is comfortable and homely. Staff were observed sitting and talking to residents’. From conversation it is evident that the staff have knowledge of the residents situations, needs and family life. It is positive that once again the majority of past requirements made have now been met. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 6 The manager and deputies as a matter of course undertake routine spot checks of the home during unsocial hours. The acknowledgement letter provided to prospective/ new residents is very comprehensive stating the needs identified and that these can be met by the home. A wipe clean board is available in the dining room where the day, date and menu options for any day are displayed enhancing orientation. The manager and two deputies hours are supernumerary to the rota giving them time to focus on managerial tasks. Relatives visiting the home looked cheerful and relaxed. A message written by one relative in the newly produced ‘comments book’ stated;” Home is first class. Very helpful and friendly”. One resident’s comments included, “The staff look after me. They are nice. Polite. I can go out when I want to. I have got no concerns or complaints”. What has improved since the last inspection? What they could do better: More diligence and attention must be paid to elimination records. Care plans must reflect what action is needed where concerns are identified. Medication systems in their present form are inadequate and unsafe with a potential to present risk to residents’. Staff recruitment processes need further development. The fact that one ancillary staff member has been appointed and allowed to work without the required checks and documents is concerning and unacceptable. Checking processes for other health professionals and the hairdresser must be instigated examples being Criminal Record Bureau screening and the evidencing of public liability insurances. Further development of adult protection mechanisms is needed. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 7 Infection control measures need tightening. Laundry and domestic staff must be provided daily. The production and implementation of quality assurance processes must be continued. 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.V285085.R01.S.doc Version 5.1 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.V285085.R01.S.doc Version 5.1 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): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 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 the following standard(s): 9 Medication systems require attention and improvement. In their present form they are a potential risk to residents’. EVIDENCE: Positive aspects were identified regarding medication systems examples being; one deputy has been delegated responsibility for medications. A form was seen on residents’ files viewed giving their consent for staff to hold and manage their medication. Information was available on file to demonstrate that doctors’ have reviewed some residents’ medication. Concerns were also identified regarding medication management and systems which include the following; although this is not the case generally controlled medication recently delivered had not been recorded into the homes’ register. The homes’ medication policy is fragmented and filed in different sections of the procedure file. The ‘home- made’ medication records leave a lot to be desired and present a potential for error. Latin abbreviations are used which could be confusing. Risk assessments’ are not carried out for residents’ who self medicate as they should be. Stock control and organisation of medication systems leaves a lot to be desired; with the shelves full of dressings and other Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 11 preparations. An olive oil bottle and calamine lotion on this shelf were both out of date. Medication records did not have a photograph of the resident attached as they should. Medication care plans are not available on file. The validity of the medication training requires confirmation from the CSCI pharmacist. Referral has been made for the CSCI pharmacist to assess the home’ medication systems in more depth and give advice. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 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 the following standard(s): 14 Residents’ are helped to exercise choice and control over their lives. EVIDENCE: Positive aspects regarding the upholding of residents’ rights were identified. All residents’ are able and many do, bring into the home with them varied personal possessions ranging from small pieces of furniture to pictures and ornaments. Residents’ information is made available to the relevant agencies to enable them to vote if they wish. Information pertaining to independent advocacy services and other organisations is on display in the home. It was positive to see on residents’ files viewed a document saying;.. Is aware of their right to access care plan and personal file”, these documents had been signed by the resident or their chosen representative. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 13 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): 18 Further development is needed to ensure that policies and procedures are in place to protect residents’ from abuse. EVIDENCE: It is positive that existing staff have all received abuse awareness training. There have been no allegations or incidents of abuse. In-house policies and procedures are in place to protect vulnerable adults examples being; missing persons and violence and aggression. The manager was able to provide a flow chart reference guide for staff to follow if an incident or allegation of abuse were to occur. The manager was not aware and confirmed that the home does not have a copy of Dudley MBC adult protection procedures titled ‘ Safeguard and Protect’. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 14 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): 26 Further developments in respect of infection control are needed to ensure that the homes’ environment is adequately hygienic. EVIDENCE: It is positive since the last inspection that cleaning schedules coving all areas in the home have been produced and implemented. Certain areas an example being the windows were seen to be extremely clean. No offensive odour was detected in the areas viewed in the home. The home provides domestic/laundry staff cover (one person doing a joint role) five days per week. On the day of this visit however, the staff member responsible for this work was not on site. Dirty laundry was waiting to be washed, the laundry floor soiled and the sink in need of a good clean. Whether or not this work had accumulated over the weekend or was due to their being no cleaner that day was not fully confirmed. There was a lack of waste bins in toilets and bathrooms. Clean washing was seen drying in the first floor bathroom- which could transmit bacteria if Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 15 touched by someone who had not washed their hands/washed their hands properly. It was noted that not all staff have received infection control training. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 16 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): 28,29. Residents’ are in safe hands at all times. Residents are being placed at risk by non-conformance to safe recruitment practice. EVIDENCE: It is positive that out of the 15 care staff employed 7 have to date achieved N.V.Q level 2 or above. Two other care staff are working towards this award at the present time. It was disappointing to determine that none of the required checks had been carried out or documentation obtained for the handyperson who has access to residents’ bedrooms and works very much unsupervised. Requirements have been made previously in relation to shortfalls in safe recruitment practices. No enhanced disclosures were available for the hairdresser, chiropodist or other visiting professionals. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 17 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): 35,36,38. Financial interests of residents’ are safeguarded. Staff are appropriately supervised. Further developments are needed to safeguard health and safety within the home. EVIDENCE: The manager confirmed that no money is held by the home in safe keeping for the residents’. For hairdressing or other purposes residents’ or their relatives are invoiced and then they make payment. Four staff files were examined to determine the level and frequency of supervision provided. Generally this was positive, frequency equating to two supervisions every twelve months. Staff meetings are also held on a fairly Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 18 regular basis. Managers and deputies undertake ‘spot’ checks/ supervisions of the home during unsocial hours. Staff spoken to were positive about the support they receive. One said; “ We are well supported by managers and seniors. Another said; “ We are supported by managers. They ‘pop in ‘ to check”. Maintenance and service certificates were randomly examined and were found to be satisfactory. Hoists were serviced in Feb 2006, the stair lift serviced in November 2005. A 5 year test of the fixed electrical wiring was undertaken in August 2004. The fire alarm system, fire extinguishers and emergency lighting were all serviced by an engineer in June 2005. There was evidence of regular in-house checks of fire fighting systems and appliances, last done on 3 March 2006. West Midlands Fire Service carried out an inspection and inspection follow up in 2005 when they approved the homes’ fire risk assessment. A potential tripping hazard was identified in room 16. The carpet requires stretching. The manager must ensure that all persons entering the home to work examples being; the hairdresser, chiropodist etc all have valid, adequate liability insurance. The kitchen felt very warm. The cook said; “ It is very hot in here”. Although ventilation is provided evidence is needed to ensure that this is adequate. At present there is no checking of the air temperature in the kitchen. The manager is producing a new training matrix. The one viewed lacked dates. Training in all areas must be able to be proven at all times. Night staff are lacking food hygiene training/certificates which would prevent them being able to prepare snacks for residents’ if requested during the night. Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 19 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x 2 STAFFING Standard No Score 27 x 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 3 x 2 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 20 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 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: Who is responsible if a breach occurs. Timescale of 01/11/05 not fully met. The registered person and manager must ensure that where recording methods are implemented for example the elimination recording chart that these are completed consistently. Timescale of 25/09/05 not fully met. Concerns must be included in care plans. Staff must be instructed on what they must do if they identify concerns. Timescale for action 01/05/06 2 OP8 12(1)(a) 01/04/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 21 3 OP9 13(2) 4 OP9 13(2) The registered provider and manager must ensure that an up to date( no older than 12 months) pharmaceutical guide is available at all times. 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; How Allendronic acid for one resident should be administered. 01/04/06 06/04/06 5 OP9 13(2) 6 OP9 13(2) How ‘ when required ’ medication should be administered. A documented risk assessment 25/03/06 must be carried out and retained on file for each resident who self medicates. This relates to all medications whether they are oral tablets, topical preparations etc. The registered provider and 15/03/06 manager must ensure that all incoming controlled medications are recorded on receipt. This to include controlled medications. The registered provider and 01/04/06 manager must instruct their pharmacy provider to provide ‘ pre-printed’ medication records. The registered provider and 01/04/06 manager must ensure that Latin abbreviations are not used on medication records. 01/04/06 The registered provider and manager must ensure that all topical preparations are date labelled when opened. 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 22 10 OP9 13(2) The registered provider and manager must revise the homes medication policy. The policy must be produced as one document to allow easy access to staff. The policy must include the following; Ordering. Receipt. Storage. Administration. Disposal. Medication errors. Medication refusals. The management of ‘ as needed medications’. Controlled drug management. Key safety. Covert medication. Homely remedies. 7 day medication retention after death. 01/04/06 11 OP9 13(2) The registered provider and manager must ensure that ; Medications stored in the kitchen fridge are kept in a separate, labelled container. Daily temperatures of the medication fridge are taken and recorded. 20/03/06 12 OP9 13(2) The registered provider must purchase a ‘ maximum and minimum thermometer for the monitoring of medication room temperatures. Temperatures must be checked and recorded at least dailypreferably at lunchtime. 20/03/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 23 13 OP9 13(2) The registered provider and manager must ensure that the temperature of the small fridge in the treatment room is taken daily and recorded. Confirm that this fridge is suitable with the CSCI pharmacist. The registered provider and manager must ensure that the reason each unwanted medication is being returned to the pharmacist is detailed in the ‘returns’ book. The registered provider and manager must ensure that each resident’ medication record has an up to date photograph of them attached. 23/03/06 14 OP9 13(2) 20/03/06 15 OP9 13(2) 10/03/06 16 OP9 13(2) 17 OP18 13(6) The registered provider and manager must ensure that an audit/clear out of the medication room is undertaken regularly to ensure that no items dressings etc are out of date. No excess stock accumulates. The registered person and manager must ensure that; A copy of Dudley Councils’ adult protection policies and procedures titled ‘Safeguard and Protect’ are available in the home at all times. That all staff read, sign and date these procedures. 01/04/06 01/04/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 24 18 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 : The redecoration of lounges. Timescale of 01/11/05 not fully met. 01/05/06 19 OP25 23(2)(p) The registered person and manager must ensure that the lighting in all rooms meets the specified LUX standards. Timescale of 01/11/05 not met. 01/05/06 20 OP26 13(3) 18(1)(a) The registered provider and manager must ensure that domestic / laundry staff are provided every day. When on holiday/sick the post must be covered. 25/04/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 25 21 OP26 13(3) The registered provider and manager must ensure; That the laundry is adequately clean at all times. That bags containing dirty washing are not stored directly on any floor- including the laundry floor. That waste paper bins are available in bathrooms and toilets. That material towels are not used in communal toilets and bathrooms. That washing is not left to dry in bathrooms. 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. Timescale of 12/09/05 not fully met. No CRB/POVA list check done for the handyperson. The registered person and manager must ensure that a professional reference is obtained from each prospective staff members immediate last employer. Timescale of 12/09/05 not met. No references on file for the handyperson. 25/03/06 22 OP29 13(6) 19(2) 06/03/06 23 OP29 13(6) 19(2) 06/03/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 26 24 OP29 13(6) 19(2) The registered provider and 20/03/06 manager must ensure checks are carried out and documents obtained for the handyperson the same as any other staff member. In the interim period the handyperson must not at any time be left alone with residents’ or allowed to enter their bedrooms unsupervised. A written risk assessment must be undertaken. This from 06/03/06. 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. 25 OP29 13(6) 19(2) 01/04/06 26 OP33 26(1)(3) (4)5 The registered person must carry 06/04/06 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. Timescale of 12/10/05 not consistently met. The registered person and manager must ensure that the homes quality assurance/ quality monitoring systems cover all required areas detailed throughout standard 33. Timescales of 1.1.05 and 01/11/05 not fully met. 27 OP33 24(1)(2) (3) 01/07/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 27 28 OP38 13(3) 16(2)j 18(1)a The registered person and manager must ensure that no staff are involved in food preparation or serve food unless they have a valid food hygiene certificate. Timescale of 12/09/05 not fully met. 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’. 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 all staff (Including the handyperson) have valid certificates in respect of the following; Fire training and drills. Moving and handling. Infection control. First aid. Dates for this training to be delivered must be provided to the CSCI. The registered provider and manager must ensure that the carpet in room 16 is stretched as it is a potential tripping hazard. 01/05/06 29 OP38 17(2) 06/04/06 30 OP38 13(2c)5) 18(1a) 23(4 01/05/06 31 OP38 13(4) 30/03/06 Westfield Lodge DS0000025040.V285085.R01.S.doc Version 5.1 Page 28 32 OP38 16(2)(j) 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. 25/03/06 33 OP38 13(3) 34 OP38 13(4) 23(2)(p) The registered provider and 06/04/06 manager must ensure that the kitchen is not used as a thoroughfare to other areas. The registered provider and 06/04/06 manager must ensure that there is adequate ventilation in the kitchen. A wall thermometer must be purchased installed temperatures must be taken and recorded twice daily once main cooking time of the day. 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.V285085.R01.S.doc Version 5.1 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.V285085.R01.S.doc Version 5.1 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. 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!