Inspection on 07/01/08 for Westfield Lodge

This inspection was carried out on 7th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westfield Lodge 22/08/06

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 Joan Franklin Key Unannounced Inspection 7th January 2008 09:00 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.V358485.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.V358485.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.V358485.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 22nd August 2006 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-£430 per week. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service that need further development. One inspector undertook this fieldwork visit to the home over one day. The home did not know that we were visiting on that day. There were 19 people living at the home on that day. Information was gathered from speaking to and observing people who live at the home. The care plans of two people were looked at to discover their experience of living in the home, and medication records were seen to focus on outcomes. Supervision notes of staff and the quality assurance system that the manager intends to implement were also viewed. There were discussions with three members of staff. The local GP was spoken to whilst he was visiting the home to see a patient. Three friends and three family members of people who live in the home were spoken to during their visits for their views. One lady who lives in the home talked about herself. It was not possible to gain feedback form a number of people living at the home due to their dementia. Prior to the inspection the manager had completed an Annual Quality Assurance Assessment (AQAA). The AQAA gave information about the home, staff and people who live there. The previous inspection report and details of a complaint were reviewed as part of the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. What the service does well: People are provided with information about what the home has to offer and there is an assessment of each person before they go to olive at the home. There is an open visiting policy which makes family and friends welcome. The management of medication ensures that people receive their medication as required. The home responds efficiently to complaints. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 6 People are provided with nutritious meals which they eat in a warm atmosphere. Careful attention is provided to those who require help with eating. The manager is enthusiastic about wanting to provide a service which is in the best interest of people who live there. People told us: “it is always clean and welcoming here” “I have been the local G.P. since the home opened. The care is very good. I am only called when absolutely necessary. For a small home it is as good as you can get. Home is always ready to give supplementary foods.” “It is absolutely marvellous. I can’t fault it” “Brilliant . Medication is administered well. Brilliant with families” What has improved since the last inspection? What they could do better: There are some maintenance jobs to be completed in the home. Personal items should not be left on top of the wardrobes. The Statement of Purpose should be up-dated. Westfield Lodge DS0000025040.V358485.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. The summary of this inspection report can be made available in other formats on request. Westfield Lodge DS0000025040.V358485.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.V358485.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is excellent. People have full information about the home to enable them to make an informed decision as to whether they would like to live there. Pre admission assessments and visits to the home ensure that people know their needs can be met prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The certificate of registration is on display in the entrance hall. The home has a comprehensive Statement of Purpose which though it does require bringing up to date. Each person living in the home has a copy of their contract and there is a service user guide in each bedroom. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 10 An assessment of needs document was in place on the two files which were read. Discussions with the manager and the deputy manager concerning a gentleman living at the home provided information that attempts have been made since he was originally admitted for intermediate care for a return home to his wife. The assessment from the psychiatrist is that the gentleman should remain at the home. The manager described how she and the deputy manager visited in hospital the most recent person, a woman to be admitted to ensure that the home could respond to her needs. We were able to speak to this woman’s granddaughter who was visiting her grandmother. The granddaughter confirmed that the pre admission contacts had been helpful and reassuring. People told us: “we were able to come to look around before coming to live here” “it is always friendly and we can visit when we want” “they talked over with my grandmother whether she wanted to share a room” Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. The people who use the service have their personal and health needs set out in a care plan. The people who live in the home are treated with respect. Attention must be made to storing personal items. The medication system is well organised though entries must be made at the time of administering drugs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two case files were reviewed. The case file system was clear with separate headings making it easy to reference the personal and medical needs of the person using the service. The home continues to include the person who lives there in the care planning review although the levels of dementia prevent full understanding of the details in the care plans. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 12 The manager said that the home has good working relationships with authorities who fund people who use the service. The care plans are reviewed regularly without difficulties. The manager forwarded to the Commission the details of a review held a few days after the inspection concerning a lady whose dementia is deteriorating to the extent that she with the approval of her family is cared for most of the time in her own room where she has stimulation from her radio and television. She has no nursing or health care needs other than her dementia. We observed that staff were a tentative to the lady whose presentation was clean and thoughtfully dressed. The manager and a senior member of staff described how the acquisition of a medical trolley has improved the dispensing of medicines. The medicines are kept in a room in the kitchen. This small room was in immaculate condition. There are no controlled drugs on the premises though following advice form the pharmacist the senior member of staff said that she keeps temazepam in the controlled drugs cupboard. There are good records of medication coming in and out of the home. There was an entry missing on a chart for the morning of the day of the inspection. The senior member of staff said that she would attend to this immediately and that as could be seen from the rest of the medical charts this is not the usual standard of keeping the records. On the tour of inspection there were items of personal dressings on top of wardrobes in the bedrooms. The deputy manager said that the district nurse will be told that these bulky and personal items should be returned to the medical room. The hoist in the downstairs bathroom has been inspected in the last year. The deputy manager said that the people who live there are very ready to have a bath as the hoist provides security. All the people who use the service were well presented. One lady was keen to show us her clean clothes. The care plans that were looked continued to have details of monthly weights of the two people who live there. We observed that staff were polite and respectful to the people who live there. One member of staff was particularly outgoing with helping people to walk around and to use the toilets. Staff were observed to knock on doors before entering. There are screens in the shared bedrooms for privacy. The deputy manager said that some attention should be given to asking people who live there if they would like a screen. People told us: “I have been the local G.P. since the home opened. The care is very good. I am only called when absolutely necessary. For a small home it is as good as Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 13 you can get. Home is always ready to give supplementary foods. Home prevents bed sores more than the local hospital where I visit patients” “The home has taken good care of my grandmother’s eczema which has greatly improved since she came to live here.” “My mother has injections from the CPN. She has been well cared for here.” In discussions with the manager after speaking to the daughter of a woman who lives at the home information was provided that no-one has injections. There is a recommendation that the manager talks to the daughter about her mother’ medication. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14.15 Quality in this outcome area is good. The people who live in the home receive appealing meals. Friends and families are fully encouraged to keep contact with the people who live in the home. Activities are arranged. It is necessary to continue to look at developing activities and the interests of people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for the people who live at the home now have details as to whether they like to get up in the morning when the wake or if they would like a cup of tea in bed. We were able to talk to several visitors who had come to see relatives or friends. Some of the visits took place in the lounge. One woman was having her regular visit from a friend in the dining room where there were talking over things which interest them. The friend was trying to encourage the woman who live at the home to continue her former hobby of reading but there was not an enthusiastic response. Later we did see the woman playing card games Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 15 with a smile on her face. The manager said that they will continue to offer to obtain large print books if she would like to read them. The home now has an activities co-ordinator. In the afternoon there were several activities in the lounge including playing cards; craftwork; and other games. The people who live there talked about the exercises that they do in the lounge area. This activity was enjoyed by some people. One woman showed how she has had her nails done recently. One woman spends most of her time in her room due to the extent of her dementia. One gentleman chooses to stay in his own room for much of the time. He told us that he likes to watch his television and that he eats his meals in the dining area. The menus are put on the wall in the lounge each morning. There is a choice for the main meal. The observation of the main meal of the day was that this was unhurried and that there was some lively chatter form staff and from some of the people who live there. Staff were carefully assisting those people who required assistance to eat. We did ask some of the people who live there whether they enjoy their meals. The responses were limited. We thought the hesitation was partly due to not knowing the inspector. During the afternoon a gentleman who lives at the home reminded staff that he had not had his afternoon tea which he likes at a time earlier than the rest of the people who live there. Arrangements were made to make his tea. The kitchen was briefly assessed. It was clean and welcoming. There was a variety of foods. There are two freezers in the garage. The foodstuffs were labelled and up-to-date and again there was a variety of foods being stored. People told us: “the food is always good” “I enjoyed the game of cards” Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Complaints procedures are in place to enable people who use the service to make complaints. There is a speedy response to complaints. Processes are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received details of a complaint since the last inspection. The complaints were that there was an unpleasant odour, the people who live at the home are not adequately supervised and that the home is in a poor state of repair. The manager replied to the complaints. Her view was the complaints had been made by someone who used to work at the home and the intention was malicious. The manager has changed the layout of the home which provides an easier view of those who are sitting in the two lounges. There has been no further action. The manager said that she has received no other complaints. There does remain a slight odour in the entrance hall. The toilets are near to the hall. The toilets themselves do not smell. The deputy manager said that they continue to find a way to eliminate the odour. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 17 We did similarly to the last inspection by spending time observing staff taking people who live there to the toilet and looking to see if there were any signs of delay in people going to the toilet. There appeared a comfortable approach to taking people to the toilet and no-one was seen to have signs of being wet or dirty. In the garage where the washing is done the cleaner had thoroughly cleaned the pots from the commodes. The manager said that she and the registered provider had discussed the requirement from the last inspection that all visiting professionals and trades people have CRB checks. She said that they have not found it possible to do this with the hairdresser and chiropodist. The manager said that the people who live there are not left alone with any person providing a service as part of their policy to safeguard those in the home. The training records of members of staff were seen. They have received Protection of Vulnerable Adults training during the summer of 2007. The manager said that she has made staff aware that certain incidents must be reported to the Commission to comply with registration. The home has current insurance liability cover. The manager said that there has been no repeat of employing staff without all the pre employment checks. She said that only one member of staff has commenced employment since the last inspection. The manager said that if a prospective employer had received the POVA check and there was a staff shortage she would contact the Commission to ask for approval for the person to commence work. People told us: “the home always smells nice” “I would go to the manager if I was concerned about something” member of staff Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. People live in a home which is comfortable and clean. There are plans to improve the surroundings and keep the home maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the cleaning and laundry duties have been allocated to ensure that the washing is done by one person and that care staff do not have to do this. The laundry is done in the garage where there are now separate areas to put the dirty washing and that which has been washed and dried. People who live in the home have their separate washing bags and baskets to keep their own clothes. The deputy manager said that the plan is to put laminated flooring in certain places when it is necessary to have replacement flooring. One bedroom where Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 19 the person has difficulties reaching the commode has had laminated flooring which the deputy manager said has improved preventing an odour in the room. On the tour of the home the bedrooms were being aired. They were clean with towels and toiletries attractively prepared fro the people who live there. There were personal dressings which are bulky left on top of the wardrobes. There is a recommendation remove these. One of the women did not want the inspector to go into her room when she was asked by the deputy manager. There was no known reason for this. The deputy manager said that this person spends time in her room on her own. Later we could hear her in her room where the door was open. In one of the upstairs bathrooms there was no floor covering around the base of the toilet. There is a requirement that floor covering should be fitted. One of the gentlemen did comment that the home is cold and that he would like it to be warmer. We thought that the home downstairs where people were sitting was warm. The deputy manager said that this gentleman makes the same comment to visitors. The deputy manager said that his wife visits him everyday and that there is an opportunity for him to return to his own home but that this has not been achieved. The home is generally presentable though there are some areas which need some attention. The area in front of the patio still needs attention. The manager said that there is a self employed maintenance man who will do jobs. We did see him leaving the home in the morning. There is an occupational therapist’s assessment dating form June 2004 which the manager said she uses as a reference to help maintain a safe and suitable environment for the people who live there. People told us: “my grandmother is comfortable here and she likes sharing her room” “these are terrible people here”, comment from a woman who lives in the home who then winked at the inspector. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. People who live in the home are cared for by staff who are trained to meet their individual needs. The recruitment process follows pre employment conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and deputy manger said that they consider that the staff ratio is good. However they have been able to advertise for 16 and a half hours post which will mean that it is easier to cover holidays and sickness as up until now existing staff have covered the hours. The manager and the deputy manager consider that the rota system, which commences at 7.30 am through till 4.00pm with a supervisor and 2 care staff works well. We observed that there was an constant activity in the home with what appeared as sufficient staff to deal with situations as they arose. There is now an activities coordinator. In the afternoon there was a variety of activities in the two lounges. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 21 We talked to the cleaner who also does the laundry. She said that she considers that the systems work well at the home and that she is kept in touch with what is happening. We spoke to a senior care staff who has a particular responsibility for managing the medication system. She was enthusiastic about her job and approves of the acquisition of a medical trolley which has improved the administration of the medicines. We looked at supervision documents which were recorded up to the end of December. The records showed that discussions took place with members of staff about their attention to the care of the people who live there. The records stated that staff had been thanked fro the work that they had done over the year. The manager said that she is assisted by the deputy manager to supervise staff. She regards that as an appraisal system as well as for supervision. The manager and deputy manager said that they consider the night staff system works well. This includes 2 hourly checks of the people who live there and more frequent if someone is unwell. The night staff have now been trained in food hygiene. A 24 hour on-call service is available from the managers. There was a brief look at training records which included attendance for POVA training in the summer 2007. The senior staff member said that she has received training for administering medicines. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. The people who live in the home have their welfare promoted and protected by a manager who manages the home in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has attained NVQ level 4 and has completed her Registered Manager’s Award. The manager completed a comprehensive Annual Quality Assurance Assessment (AQAA). The AQAA included reference to all of the minimum standards to enable the manager to assess that the home is run to achieve the Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 23 best possible outcomes for the people who live there. The AQAA has plans for improvements which rely on meeting standards and requirements. There is a reliance on quality assurance systems from hearing from people who live in the home and their family and friends. The manager showed her system for quality assurance which placed an emphasis on an annual review of all the policies and comments that had been received. It might be more effective to spread the review over the year than a single event. The manager provided details of the improvement to the recording of accidents. The accident prevention strategy she considers has improved since the last inspection and is included in her annual review as to whether systems could be improved. We saw the manager interact with the people who live there, family and friends and with staff. The assessment was that all interactions were focussed on the service to the people who live there. We assessed that there was a positive working relationship between the manager and the deputy manager. The home does not hold any monies for people who live there. The latest fire inspection report was available. The manager said that they discuss evacuation procedures as a staff team but they have not had a fire drill. Now that there has been a change in the law about smoking there is no smoking in the main building. The manager is proud that more than 50 of staff have level 2 NVQs. She said that the home would offer maximum training opportunities. The manager is going to contact Skills for Care to register members of staff. Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X x 4 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 3 x 3 Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations That each residents medication record has an up to date photograph of them to avoid medication being administered to the wrong person. That entries are recorded on MAR sheets immediately that DS0000025040.V358485.R01.S.doc Version 5.2 Page 26 Westfield Lodge 3. 4. 5. 6. OP26 OP21 OP26 OP1 medication has been given, so that medication is not administered again. Medical dressings should be stored appropriately away from residents bedrooms between use. That the upstairs toilet base is fitted with floor covering so that it can be kept clean and free from odour That the plans for improvement to decoration and replacing worn out flooring is progressed to maintain pleasant surroundings The Statement of Purpose is brought up to date so that people are made aware of the change of layout in the home Westfield Lodge DS0000025040.V358485.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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