Inspection on 08/08/06 for Westfield Lodge Nursing Home

This inspection was carried out on 8th 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 Nursing Home 20/02/09

Westfield Lodge Nursing Home 29/02/08

Westfield Lodge Nursing Home 28/12/05

Westfield Lodge Nursing Home 01/09/05

Westfield Lodge Nursing Home 26/01/05

Westfield Lodge Nursing Home 04/08/04

Westfield Lodge Nursing Home 17/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Westfield Lodge Nursing Home Weston Coyney Road Weston Coyney Stoke-on-Trent Staffordshire ST3 6ES Lead Inspector Mrs Yvonne Allen. 2nd inspector Mrs Lynne Gammon Key Unannounced Inspection 8 August 2006 10:30 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 Nursing Home DS0000026971.V307727.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 Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield Lodge Nursing Home Address Weston Coyney Road Weston Coyney Stoke-on-Trent Staffordshire ST3 6ES 01782 336777 01782 598368 westfield.lodge@ashbourne.co.uk the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Ashbourne Homes Limited, Ashbourne Consolidated Group 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) Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54), Physical disability (54), Physical disability of places over 65 years of age (54) Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 54 Physical Disability (PD) - Minimum age 60 years on admission. Date of last inspection 28th December 2005 Brief Description of the Service: Westfield Lodge is a purpose built nursing home admitting service users over 65 of age that require personal and nursing care. The home was built about 17 years ago. Accommodation is to two floors, bedrooms are single occupancy and some have an en-suite facility consisting of toilet and wash hand basin. There are three lounges - one to the first floor and two on the ground floor. There is a separate dining room. The two floors are accessed via a passenger lift. There is a central kitchen and laundry. There are bathrooms and toilets sited on both floors. There is limited garden area but a small conservatory opens out on to a smallgrassed area with a high-level flowerbeds and seating area. There is parking space for several cars. The home is situated two miles from Longton town centre and a short walk allows access to bus routes. The fees charged by this home range from £270.00 to £528.00. Additional charges are made for hairdressing, activities and private chiropody. This information was provided in the Pre Inspection Questionnaire received by the CSCI on 13/06/06. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was carried out by two inspectors and took four hours to complete. All the key standards were assessed and the following methods were used to gather evidence to support judgements made – Direct observation Examination of records and documentation Case tracking of four residents Discussions with residents, relatives and residents Interviews with two staff members Discussions with the acting manager Tour of the home The inspectors arrived at the home at around 10.30am and were made to feel welcome by the staff and residents and staff were helpful. On entering the home the inspectors were welcomed by the deputy manager who was acting as manager. The Registered Manager had recently transferred to another home within the group, and this position was now vacant at the home. There was a pleasant and relaxed atmosphere at the home. Residents appeared happy and were chatting amongst themselves in the communal areas. Staff were busy carrying out personal care and one staff member was giving out the morning drinks. Comment cards had been received from residents and their relatives prior to this inspection visit and the following are their thoughts about this home – “Mum feels the staff could spend more time with her when dressing her in the morning.” “Laundry seems to always get mixed up.” “Sometimes clothing is very dirty and untidy.” “Night staff are always available.” “I cannot take part in some activities.” “I am happy to live here.” Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 6 “Did not know anything about the home until I moved in.” “Everything is satisfactory.” “The best thing I did.” “Staff are very good to me.” “100 for cleanliness.” The results of the comment cards are that, in relation to the provision of staff 50 feel that there are not enough staff around during the day and that staff do not often have the time to spend with them, whilst the other 50 felt satisfied with this. In relation to presentation of the home most felt that it was kept clean and well presented. On the whole most residents and relatives were satisfied with the meals provided but some residents were not and felt that there were areas for improvement. The provision of therapeutic activities was an area where most residents and families felt that there was a need for improvement. Overall the majority of residents and their families felt satisfied with the care and support they received at the home. It was identified that there was one requirement still outstanding from the last inspection report. This was in relation to replacement of windows throughout the home. Some requirements and recommendations were made as a result of this inspection and timescales were agreed with the acting manager during feedback at the end of the inspection visit. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: The cleanliness of the home could be improved. There were areas in need of a thorough clean especially doors, woodwork and some of the carpets. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 8 A requirement in respect of redecoration and refurbishment throughout the home had only recently started to be addressed and was slow to take effect. This needs to be developed more quickly as the home was looking worn and tired. Some of the carpets were in need of replacement and a previous requirement to replace blown windows had not been fully addressed. Advice must be sought from the fire safety officer in relation to the propping open of doors. NVQ staff training needs to be addressed within the home. Staff spoken to were feeling despondent and disillusioned with the lack of progress in this area. The provision of social and therapeutic activities for residents in the home was poor and individual needs were not being met in this area. The meals provided need to be improved both in quality and choice. The majority of comments received about this were negative. Seating arrangements for dining need to be reviewed so that there are enough tables and chairs and all individuals have the opportunity of taking their meals in the dining room if they so wish. Individual care plans must contain evidence of regular reviews. The providers should ensure that personal autonomy is upheld for residents and that there is evidence of preferences and choices are respected in relation to aspects of daily living in the home. It was identified that residents accommodated in this home have a voice but comments received were very mixed and it was difficult to assess whether their opinions are taken on board. Individual opinions about the running of the home need to be taken more seriously and acted upon and there needs to be evidence of this. 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 Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 9 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 Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 10 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): 3, 4 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals were only offered a place at the home following an assessment of their needs. Individuals entering the home could be assured that most of their assessed needs would be met but there may be areas, which do not meet their expectations and where the home needs to improve. EVIDENCE: Four residents were case tracked as part of the inspection visit where individual plans were examined. The plans confirmed that assessments had taken place prior to admission by a qualified nurse during which specific needs had been identified. A letter had then been sent to residents confirming that the home would be able to meet these assessed needs. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 11 One comment card read – “I did not know anything about the home until I moved in.” Another comment read – “I was told about the home when I moved in.” There are examples, throughout the report, that some individuals’ needs are met well by the home and some very positive comments were made from residents. However, in some areas, there was evidence to suggest that there is a need for further development in order to ensure that specific individual needs are met as planned. Some of the comments from residents and relatives identified this and have been included in the report. Social and therapeutic needs require review and further development. A number of residents commented that meals were not up to their expectations. Some of the care plans examined had not been evaluated and reviewed as planned. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care was planned and delivered with dignity and respect. The personal, nursing and health care needs of individuals were met with evidence of good multidisciplinary working but reviews were somewhat inconsistent. EVIDENCE: Case tracking of the four residents continued and further examination of their individual plans identified that personal, healthcare and nursing needs were being met on a continual basis. There was evidence of visits by professionals and advice and treatment had been sought from them. The care plans were detailed and informative. It was identified that some reviews had not been carried out as planned and this was discussed with the acting manager and a requirement has been made in respect of this. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 13 The plans contained evidence of communication between named nurses, key workers and individual residents and their representatives. The procedures, storage and recording of medication was assessed during further case tracking. All the above was found to be in order. The inspectors were informed that the home was in the process of changing pharmacy suppliers. Several residents were spoken to and all were complimentary about the home and the care they received. Comments included – “I like being here. I have been here for a long time and get to see my doctor. I am taken care of well.” “No complaints really – not enough to do sometimes.” Another resident commented – “no problems. Staff not bad.” A resident who was lying on his bed on continual Oxygen therapy was very complimentary about the care he received and the staff who looked after him. He had everything to hand and his bedroom had been moved around to suit his needs and abilities. Another resident who was tube fed had recently stared to eat small amounts following reassessment. She commented that she was very happy with the staff and that “it was lovely to have real food again.” A number of visiting relatives were spoken to during the inspection. Those spoken to were satisfied with the services provided. Care staff were observed addressing residents with respect and were mindful of dignity and privacy. Westfield Lodge Nursing Home DS0000026971.V307727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not always able to exercise choice and control over their lifestyles in the home especially in respect of social activities and meals. EVIDENCE: Comments received from residents and their families suggested that social and therapeutic activities in the home were not as good as they should be. One comment read – “Residents appear to lack stimulation and conversation, sitting in chairs for hours between meals.” Another comment read - “I cannot take part in some activities.” It was observed, at the time of the inspection visit that residents were asleep in both lounges downstairs and there was no activities or stimulation taking place. This was discussed with the acting manager during feedback and she stated that the programme of activities was being revised and developed. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 15 Entertainers visit the home on a regular basis and residents spoken to confirmed this. There was written evidence that residents have their religious and spiritual needs assessed and that theses needs are met as much as possible. There are Church services held monthly at the home. The catholic priest was seen visiting a resident at the time of the inspection and the inspector was informed that he visits often. It was difficult to assess whether personal autonomy was maintained at the home as this was an area where there were some mixed comments and feelings. Comment cards received contained positive and negative comments about food, meals and personal choice. Comments included “I am happy to live here.” “I see my relatives and go to my room when I like. I get up when I want to and go to bed when I want to.” “Too often in nightclothes from early afternoon.” “Mum feels the staff could spend more time with her when dressing her in the morning.” “Laundry seems to always get mixed up.” The provision of meals was an area where there were mixed feelings and where some residents felt that there could be improvements. Residents felt that there was not enough choice and variety and that sometimes the quality of the food was not good. Some staff spoken to also confirmed this. The quality of the food served for lunch was poor. The burgers were hard and difficult for residents to cut up. The alternative was meatballs. Not all residents could be seated in the ground floor dining room at a dining table, as there were not enough tables and chairs for everyone. A number of residents were sitting in a small adjoining foyer in easy chairs with over bed tables to eat their meals. The residents spoken to stated that they had become used to this now and wanted to stay where they were. However, as there was not enough room for everyone the initial choice had been taken away from individuals. The home did not make best use of the space it had available as no one was dining upstairs where there was more room. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 16 This was a matter of concern, which had been raised in the last report and was discussed with the acting manager during feedback. Staff were observed helping residents who needed assistance with their meals. Some residents were served meals in their bedrooms at their request. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It was evident that concerns were taken seriously and acted upon but the provider will need to ensure that all residents are made aware of who they are able to speak to should they have any concerns. Residents could also be assured that the systems in place help to keep them safe at the home EVIDENCE: There was a clear and accessible complaints procedure displayed in the entrance to the home. The acting manager explained that she liked to deal with concerns before they became complaints and that she records the action taken. She also has support from the Company Regional Manager in dealing with complaints. The CSCI had not received any complaints directly about the home during the last 12 months. Comments received from residents were mixed. Whilst those spoken to on the day of the inspection stated that they would know who to go to if they had any Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 18 concerns, three comment cards read that residents in the home do not know how to make a complaint and did not always know who to speak to. Residents are safeguarded from harm or abuse by the robust systems in place at the home and staff spoken to were aware of the local procedures relating to Adult Protection. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 19 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe comfortable, home, which has been adapted to meet their needs and which would be enhanced by further attention to cleanliness and development of the redecoration and refurbishment programme. EVIDENCE: A tour of the home was conducted during which all of the communal areas, a selection of bedrooms, the laundry and the kitchen were inspected. Some of the bedrooms had undergone redecoration and refurbishment and were attractive and well presented. This programme of redecoration now needs to be continued to include the remaining bedrooms. It was noted that the bath in the bathroom opposite room 10 was in need of re-enamelling. In bedroom 47 there was no headboard in place and no reason for this. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 20 Most of the bedrooms were very personalised and the layout was suited to the needs of individual residents. Residents could bring personal items into the home, including small items of furniture, with the agreement of the manager. The home had been adapted to meet the needs of residents with limited mobility and there was evidence of aids and specialist equipment around the home. The grounds were accessible to residents including those using a wheelchair. The gardens had been tidied up since the last inspection and were now more presentable. The bedroom doors and woodwork throughout the home were in need of a thorough clean and in bedroom 47 the wall was dirty and stained at the top of the bed. Some of the carpets were badly stained and in need of a thorough clean or replacement as necessary. The door to bedroom 17 was particularly dirty. This door was also found to be propped open with an empty pop bottle. The propping open of doors was discussed with the acting manager and it is a requirement that advice is sought from the local fire safety officer in relation to this. There were some windowpanes where the seals had blown causing them to mist up. These were noted during the last inspection and a requirement to replace these had not been addressed. These must now be attended to without further delay. There is a part time maintenance person employed at the home and his records relating to maintenance of the home were examined. These were up to date and in order. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are carefully selected to work at the home and possess the necessary skills to care for the residents. Ensuring that NVQ training was accessible would enhance staff skills and expertise. EVIDENCE: At the time of the inspection there was a total of 42 residents accommodated with 1 resident in hospital. 33 of the residents were in receipt of nursing care. The Care Manager was working as Acting Manager and was working as supa numery at the time of the inspection. She stated that worked 24 hours last week and 36 this week as management hours. She then worked her other hours on the floor as a nurse. There were two first level qualified nurses working from 7am until 5pm. After this time there was 1 nurse on duty during the evening shift and 1 throughout the night. From 7am until 2pm there were 7 care staff working alongside the nurses and from 2pm this number dropped to 5. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 22 On night duty there were four care staff working with the nurse. 30 hours maintenance support was provided. There was a full time administrator provided. Part time laundry cover was in place. Domestic hours were provided but these should be reviewed as to whether the number of hours provided is adequate for this home. The kitchen was staffed with cooks and assistants and had recently changed from being run by an outside contractor to being run by the same company who owns the home. The acting manager stated that this would mean that the company could make its own arrangements including improvements in this area. The inspector was informed that the activities co-ordinator had recently left and this position was currently vacant. Discussions with various staff members confirmed that the NVQ training for staff had diminished and that there had been problems accessing and completing courses. One staff member had had her folder lost by the previous trainers. Staff had been left feeling frustrated and demoralised. It is a recommendation that NVQ training courses are accessed for staff and that staff are allowed to complete their courses. Staff spoken to confirmed that they receive regular updates in mandatory health and safety training including fire safety and moving and handling techniques. Records were seen to confirm this. The staff recruitment procedure was assessed and found to be robust. Three employee files were examined and all the required information was present including CRB checks and references. The staff were found to be somewhat unsettled with the change in management although they were all complimentary about the Care Manager stating that she was supportive, accessible and helpful. They stated that, on some occasions, there had been staff shortages and that there had also been an increase in dependencies of individual residents. This had had an effect on staff moral and they were feeling tired and somewhat disillusioned. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 23 Examination of the staffing rota over a specific period of time identified that the numbers of staff provided was adequate for the number of residents accommodated. Residents’ dependencies are assessed monthly by the home. It was suggested that this could be a topic for discussions at the next staff meeting. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there is a requirement for the proprietor to provide a Registered Manager for this home, the interim arrangements for management are satisfactory and the home is run in the best interests of the residents who live there. EVIDENCE: The Registered Manager of the home had recently moved to another home within the Company and the Care Manager was on a six-week trail acing up as Manager. At the time of the inspection the home was running smoothly and efficiently. The residents and staff were all complimentary about the Care Manager. Staff felt supported by her and residents felt that she was accessible and caring. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 25 As the Care Manager also worked on the floor as a nurse she was readily available to residents and their relatives. She also stated that she made herself available at weekends and evenings so that she was accessible for all relatives. Regular residents’ meetings were held at the home where individuals were able to air their views and make suggestions for improvements. It could not be identified whether the wishes of the residents had been upheld or taken into account, however. Discussions with residents and staff members confirmed that these meetings took place. Minutes of the meetings were also available. The Acting Manager audits the services provided by the home on a regular basis. Records were seen of monthly home audits. The Company Regional Manager also carries out audits at the home and the results of monthly visits are sent to CSCI under Regulation 26 Reports. Records of formal staff supervision were inspected and staff confirmed that they received regular supervision. The Acting Manager and maintenance person work together to ensure that a healthy and safe environment is provided for staff to work in and residents to live in. Records and documentation were examined in relation to this and were all found to be up to date and in order. The required testing and maintenance of equipment had been carried out. Risk assessments had been developed to ensure safety of residents and staff. Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 26 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 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 x x 3 3 3 Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 27 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 OP25 Regulation 23(2) d Requirement The remaining windowpanes where the seals have gone must be replaced or new seals provided. PREVIOUS REQUIREMENT. Care plans must be reviewed regularly as required and this must be documented. The provider will need to ensure that social and therapeutic needs of individual residents are catered for. The standard of meals served at the home must be improved The standard of cleanliness around the home must be improved Doors must only be propped open with equipment recommended by the fire safety officer and advice must be sought in respect of this Application must be made to the CSCI in respect of Registered Manager for this home Seating arrangements for dining need to be reviewed so that there are enough tables and chairs and all individuals have DS0000026971.V307727.R01.S.doc Timescale for action 08/10/06 2 3 OP7 OP12 15(2) b 16(2) m, n 16 (2) i 16 (2) j 23 (4) c 08/10/06 08/10/06 4 5 6 OP15 OP26 OP19 08/10/06 08/10/06 08/10/06 7 8 OP31 OP15 8 and 9 23 (2) g 08/10/06 08/10/06 Westfield Lodge Nursing Home Version 5.2 Page 28 the opportunity of taking their meals in the dining room if they so wish. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP26 OP28 OP14 Good Practice Recommendations A review of the laundry procedures is recommended to help avoid mixing up of residents’ clothing It is recommended that effective NVQ staff training programme is accessed for staff The provider should ensure that individuals are given choices in respect of daily living and that personal autonomy is maintained wherever possible and preferences upheld. This is especially in respect of choices at mealtimes, and choice of social activities The programme of redecoration and refurbishment for the home should include replacement of the stained carpets in areas throughout the home 4 OP19 Westfield Lodge Nursing Home DS0000026971.V307727.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home DS0000026971.V307727.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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