Inspection on 16/01/06 for Westfield Road (1)

This inspection was carried out on 16th January 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westfield Road (1) 15/12/08

Westfield Road (1) 19/12/06

Westfield Road (1) 01/08/05

Westfield Road (1) 02/02/05

Westfield Road (1) 09/11/04

Westfield Road (1) 01/03/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

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

CARE HOME ADULTS 18-65 Westfield Road (1) 1 Westfield Road Bletchley Milton Keynes Bucks MK2 2RR Lead Inspector Mrs Maureen Richards Announced Inspection 16th January 2006 09:45 Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 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 Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 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 Adults 18-65. 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 Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westfield Road (1) Address 1 Westfield Road Bletchley Milton Keynes Bucks MK2 2RR 01908 366168 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) The Disabilities Trust Care Home 3 Category(ies) of Physical disability (3) registration, with number of places Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 3 people with a physical disability. Date of last inspection 1st August 2005 Brief Description of the Service: Westfield Road is a care home for three people with a physical disability. The aim of the home is to provide rehabilitation for people with brain injury into more independent living. The home is owned by the Brain Injury Rehabilitation Trust. The day to day support and external management of the home is provided by Thomas Edward Mitton House, which is based in Milton Keynes. The home consists of a two-storey building. All of the bedrooms are single, and one has an en -suite shower. The home is situated in Bletchley, close to local shops, leisure facilities and other amenities. It is easily accessible for public transport. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection of Westfield Road took place over six and a half hours on the 16th January 2006. The inspection consisted of discussions with the registered manager, house leader, an individual discussion with one staff member, a tour of the building and examining records. The home had one service user living there at the time of this inspection. This individual did not indicate he wanted to meet with the inspector. The outstanding key standards were assessed and requirements from the previous unannounced inspection have been complied with. This was a positive inspection with the majority of standards assessed met. The home is well managed with one requirement resulting from this inspection. Recommendations have been made to further develop systems and practices within the home. One comment cards was received from an ex service user and one from their relative. Both of those comment cards were positive regarding the quality of care received. No comment cards were received from any professionals involved in service users care. What the service does well: What has improved since the last inspection? The manager and house leader are actively involved in the decision to admit a new service user. Minutes are maintained of meetings to support this. Service user files have been developed, reorganised and information made more accessible. Service user risk assessments have been developed and are reviewed and updated on admission to the home. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 6 Improvements have been made to medication practices. The home has had double-glazing fitted throughout and the kitchen has been refurbished and updated. Staff training files have been reorganised. Staff have specialist training and all mandatory training is up to date. Staff personnel files are available in the home. The house leader has attended supervision training. The registered manager and house leader have worked together in developing systems and updating filing systems and records within the home. The registered manager and house leader has been proactive in meeting requirements from the previous inspection. The house leader has developed in her role and is more confident in this role. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standard 2 was not fully assessed. Standard 2 was assessed at the previous announced inspection and requirements were made • • That the manager must ensure that she is actively involved in the decision to admit service users to the home. That the manager must ensure that staff are kept informed of who is to be admitted prior to admission to ensure that staff feel able to meet service users needs. That the manager must ensure that the admission documentation is updated to reflect admission to the home. • At the time of this inspection the home had one service user. The review meeting minutes indicate that the manager was involved in the discussions to admit the service user to the home. Staff confirmed that this was discussed at staff meetings and in handover prior to the admission taking place. The service users file has been updated to reflect admission to the home. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 Service user plans have been reorganised and are updated to reflect admission to the home to ensure that the service users needs are met in a safe and consistent way. Further improvement in relation to outlining specific details on support required is necessary to support this and to ensure that staff are consistent in meeting service users needs. Service users are supported to make decisions about their lives, which enables them to be involved in all aspects of their care and life at the home. Risk assessments are in place, which promotes the health, safety and welfare of service users. EVIDENCE: At the time of this inspection the home had one service user living there. The service user plan for this individual was seen. Service user plans have been reorganised and the information has been made more accessible. The plan includes a personal details information sheet, which outlines the date of admission to the home, personal details, next of kin details, medical history, mobility, employment, college and interests, known allergies, reference to specific injury /disability and a photograph. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 10 The service user plan includes a “rehab plan”, which outlines the support required with personal care, mobility, domestic activities and the management of specific behaviours. The rehab plan on self-care makes reference to following recommended procedures and aids, however there was no procedure included within the plan to indicate what this is. The registered manager confirmed that the service user had refused to comply with the procedure and therefore the written procedure was not put in place. Reference to this must be documented on the service user plan. The care plan on domestic activities makes reference to the “prescribed sequence”. The registered manager advised that this was encouraging the service user to complete his weekly planner. This must be specifically indicated on the service user plan to ensure that all staff are clear of what support and intervention is required. The service user file included some written communication and guidelines, however the communication was not dated or signed and it was not clear if this was still relevant. The home completes an individual daily record of what the service user has done. This is filed in the service user plan. The service user plan shows evidence of being discussed with service users but the service user chose not to sign. There is a note on the service users plan to indicate this. The service user plan did not include a date of review. The registered manager confirmed that service user plans are reviewed as part of the rehab multidisciplinary meetings, which are held fortnightly. Records of those meetings are maintained to confirm this. A requirement was made at the previous unannounced inspection that the manager must ensure that relevant “rehab plans” and guidelines are in place on admission. This has been complied with. The staff provide assistance and guidance to support service users to make decisions about their lives. The home is able to access advocates if this was required for individuals. The contact number for advocates is displayed on the notice board. The service users are supported to make their own choices, however the clinical team make decisions which may conflict with the service users choice based on risk assessments. The current service user manages his own finances and therefore there is no reference to this within the service user plan. The family supports the service users to deal with benefits. The service user plan included risk assessments. Requirements were made at the previous unannounced inspection that risk assessments are put in place on admission and that risk assessments are specific and detailed as to how risks should be managed. The risk assessments had been updated to reflect admission to the home and the action plan to reduce identified risks was more specific on how risks should be managed. This must be maintained. The risk assessments did not include the service user signature or an indication that the risk assessments had been discussed with the service user. The keyworker confirmed that the risk assessments had been discussed with the Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 11 service user but he refused to sign them. A note must be maintained on the risk assessments to indicate this. The risk assessments did not include a date of review. The registered manager confirmed that risk assessments are reviewed and updated at the fortnightly review meetings. The home has a missing person procedure in place and the service users file included a blank police missing person form with photograph to be completed in the event of a service user being considered missing. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Opportunities are made available which support and integrate service users back into work. Service users complete a weekly planner, which encourages and supports them to take part in specific activities as part of their rehabilitation. Family involvement and friendships are supported and encouraged to enable service users to develop and maintain family links and appropriate relationships. Individuals routines and choices are agreed on the weekly planner which ensures service users rights are respected and their privacy and involvement in decision-making is promoted. Service users take an active role in meal preparation, which enables them to choose their meal and develop skills. EVIDENCE: Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 13 The current service user chooses not to be involved in work placements or further education. The home has access to a vocational work placement officer who becomes actively involved in supporting service users back into work placements or college. The involvement of the vocational work placement officer is agreed at review meetings and she matches up jobs with individuals past work experiences or interests. She supports the service user in the work placement until such time as her support is no longer required and within a risk assessment framework. The home is situated in Central Bletchley and is accessible to local facilities including the library, shops and pubs. Milton Keynes is accessible by public transport. Service user plans make reference to the level of support required by individuals in using community facilities and in maintaining a neighbourly relationship with the community. The home does not have access to its own transport and service users are encouraged to use public transport as part of their rehabilitation programme. The registered manager confirmed that she can access a vehicle from Thomas Edward Mitton house if this was required for individuals. The manager confirmed that service users are registered on the electoral roll but as this is a transitional home the service users change and move on a regular basis. Staff time and support for service users is available in the evenings and at weekends. Family links and friendships are encouraged and welcome. This was indicated on the comment card received from an ex service user. Service users can choose whom to see and can see visitors in their bedrooms or in communal areas of the home. Service users have the opportunities to meet people who do not have a disability and can choose to develop and maintain intimate personal relationships. Staff knock prior to entering service users bedrooms. The service users are given a key to their bedroom and a key to the front door is made available if the service users choose to take one. Some service users are on supervised trips out of the home and during this time may not have a key to the front door made available to them. Service user plans must specifically outline when this is the case. The current service user is able to manage their own post. Service user plans makes reference to the service users preferred form of address. Staff tend to work individually with service users and therefore interact with service users and not exclusively with each other. Service users can choose when to be alone or in company. Service users are supported to attend to their weekly programme as part of their rehabilitation. Service users have unrestricted access to the home, except for the office, which is kept locked. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 14 Service users responsibility for housekeeping tasks is included on the individual’s weekly planner. The rules on smoking, alcohol and drugs are outlined in the contract. Service users take an active role in budgeting, shopping and preparation of individual meals as part of their rehabilitation programme and dependant on their abilities. Support and guidance from staff is available if required and as outlined in service user plans. A record of what is eaten is recorded on the daily record and the weekly menu plan is agreed and recorded on individuals weekly plan. Aids and equipment can be provided if assessed as being required. Service users can choose where they eat their meals and family are able to join service users for meals if the service user wanted this. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 & 19 Service users are supported to meet their personal care needs whilst promoting their independence and privacy. Systems are in place to record any medical intervention and treatment prescribed to ensure that service users health needs are met and monitored. EVIDENCE: Service users admitted to the home are physically active and specific aids and equipment are provided as required to support this. The home does not provide intimate personal care and service users are prompted and supported to meet their personal care needs as outlined within the service user plans. Service users may be prompted to get up to attend to their weekly plan. The times for going to bed are flexible but service users are made aware that they must keep the noise down after 11.00 pm at night. Service users choose their own clothes and hairstyle. Service users may have a choice of staff to do a specific task but do not have a choice of staff who work with them on a day-to-day basis. Service users have access to specialist services from the clinical team based at Thomas Edward Mitton House. General nursing care would be accessed through the GP. Service users have a designated keyworker. The service users plan did not outline the service users preferred routines, likes and dislikes. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 16 Any involvement with advocates family and friends is subject to the service users wishes and consent. Service users are registered at local GP surgeries. Records are maintained of appointments and outcomes. Service users are supported with medical conditions under the care of the GP. Service users have access to healthcare facilities such as dentists, opticians and chiropodists. Service users registered with GP surgeries for a period of six months or more are offered routine screening. Service users medication is reviewed as part of clinical review and medication prescribed by the GP is reviewed annually. Service users are supported by staff to attend appointments if this is required. Standard 20 was not fully assessed at this inspection. Standard 20 was assessed at previous unannounced inspection and a requirement made that written guidelines must be obtained from the prescriber on the use of all as required medication. The medication administration record see at this inspection did not have guidelines on the use of PRN medication. The registered manager confirmed that the home is moving over to the Boots monitored dosage system and she hopes this will improve the medication system. A requirement was made that the manager must ensure that all staff responsible for administering medication have been assessed and are deemed competent to administer medication. Written evidence must be on the staff members file. This has been complied with. A requirement was made that the local medication policy must specifically outline the procedure for disposal of medication. The medication policy makes a brief reference to the disposal of medication, which is lost within the policy document. The policy should be reviewed to include specific guidelines on the disposal of medication. Standard 21 was not assessed. A recommendation was made at the previous unannounced inspection that the local death policy should include the procedure for dealing with an unexpected death. The registered manager confirmed that those guidelines are included in the collapse of a service user policy. This policy was seen which supports this. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above key standards were inspected at this inspection. The key standards were assessed and met at the previous unannounced inspection. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Systems are in place to ensure that the home is kept clean and control of infection is maintained which promotes the health, safety and well being of service users. EVIDENCE: Standard 24 was not assessed at this inspection. This standard was assessed and met at the previous unannounced inspection. Since the previous unannounced inspection double-glazing has been fitted throughout the home and the kitchen has been refurbished and updated. Staff and service users are responsible for cleaning the home and systems are in place to support this. The home was clean throughout and free from odour. The washing machine is situated in the kitchen and procedures are in place on the management of laundry. Hand soap is provided in the toilets. The home does not usually deal with clinical waste however clinical waste would be disposed of through Thomas Edward Mitton house if this was required. Policies and procedures are in place for control of infection. The home does not have sluicing facilities but tend not to admit service users with a high level of personal care needs. If sluicing facilities were required they would be accessed at Thomas Edward Mitton House. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 35 & 36 Staff have the necessary skills and specialist training to meet service users needs. The home has safe recruitment practices in place which safeguards service users. Staff have up to date mandatory training, which ensures that service users needs are met by appropriately trained staff. Staff are supervised and supported in their role, which benefits service users. EVIDENCE: The registered manager and house leader confirmed that staff are accessible to, approachable by and comfortable with service users. They are good listeners and communicators and appear committed and motivated in promoting the aims of the home. Staff have specialist training in brain injury, crisis intervention and epilepsy. The home has a good working relationships with the clinical team based at Thomas Edward house. The manager has an NVQ 4 and is an NVQ assessor. None of the current care staff group have an NVQ. The house leader is registering to commence NVQ 3 training and this training will then be cascaded down to the other members of the team. It is hoped that NVQ training for care staff will now be escalated. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 20 Four staff files were viewed at this inspection. Staff files seen include two references and confirmation of CRB clearance. In some files the CRB number was written on the file but there was no letter from the organisation to confirm the date of the CRB and to confirm that the POVA check had been carried out. This should be addressed. Some files contained a copy of the application form, terms and conditions and medical questionnaire. Some files did not have all of this information. Files contained copies of birth certificates, driving licences and or a copy of passport. One of the files contained an up to date photograph, none of the other files contained a recent photograph. The staff files are maintained at the home, including files for bank staff. Work has commenced in bringing those files up to date with the required information. This needs to be developed. New staff receive structured induction and training. The training records indicate that all staff have up to date mandatory training. The house leader confirmed that equal opportunities training is included within the induction training. Individual training needs are identified in supervision. Staff confirmed that they receive regular monthly supervision and on going support. The house leader is responsible for supervising care staff and has had recent training in supervision skills. Staff have an annual performance review and confirmed that they are aware of the grievance and disciplinary procedures. Staff receive training in crisis intervention and polices are in place for dealing with aggression. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The home is well managed which benefits service users. The organisation has systems in place to monitor the quality of care and to ensure that standards are being maintained. The home has systems in place to ensure the health, safety and welfare of service users. EVIDENCE: The manager has recently been registered by the Commission as the registered manager of two services. She is already the registered manager of another service and intends to become the registered manager for five services in total as the registered managers of those services leave. The registered manager is based at Thomas Edward Mitton house and is available to the homes as required. The home has a house leader who is responsible for overseeing the day-to-day running of the home and she has developed and become more confident in this role. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 22 The registered manager has achieved her NVQ 4 award. She is actively involved in the development of local policies and procedures and in coordinating training for the staff teams. The manager and house leader have been proactive in meeting requirements from the last inspection and in the reorganisation of filing systems and procedures within the home. The organisation carry out Regulation 26 visits and a copy of the report of the visit is sent to the Commission. The registered manager confirmed that a quality audit of the Brain Injury Rehab Trust is carried out and a questionnaire is sent to service users, relatives, funders and other professionals. The results of the audit are collated but are not specific to each service. The registered manager agreed to send a copy of the most recent audit results to the Commission. Staff have up to date mandatory training. The home has a first aid box which is kept in the office. This was restocked in June 2005. The manager should consider a regular check of the contents of the first aid box to ensure that all items removed are replaced and to ensure that items remain within the best before dates. The home has records to confirm that the fire equipment has been serviced. Staff at the home carry out a daily visual check of fire exits and a monthly check of the fire alarm, emergency lighting and fire extinguishers. Up to date records are maintained to support this. The home carries out a fire drill monthly and record service users responses to drills. The service user living at the home likes to have his bedroom door left open at night. A risk assessment must be put in place to support this. Radiators at the home are covered and the water temperatures have been regulated. The water temperatures are checked and temperature recorded monthly. The home has a British gas service record, which indicates that the gas was serviced in December 2005. The home has an up to date fixed lighting certificate and up to dates records of portable appliance equipment. Staff at the home take and record fridge and freezers temperatures daily. The home has COSHH data sheets and a reminder for staff of COSHH regulations and employees duties and responsibilities under COSHH. The home has up to date generic risk assessments on safe working practice topics. The home has a policy on lone working, which the registered manager confirmed is due to be reviewed and updated. The home has a record of accidents in place. Local and organisational health and safety polices and procedures are in place. The organisational health and safety policy was not viewed at this inspection. The local health and safety policy was overdue for review. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westfield Road (1) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000015079.V264958.R01.S.doc Version 5.0 Page 24 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. 1 Standard YA42 Regulation 13 Timescale for action A risk assessment must be put in 31/01/06 place to identify and manage the fire risk associated with a service user leaving their bedroom door open at night. Requirement 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 YA6 YA6 Good Practice Recommendations Guidelines included in service users plans should be signed and dated as an indication as to whether those guidelines are still up to date. The manager should ensure that procedures referred to within the rehab plans are included and that all intervention required by staff is clearly explained and expanded on within the service user plan. This should be monitored and maintained. Risk assessments should show evidence of service users involvement. The local medication policy should specifically outline the procedure for disposal of medication. Staff files should be further developed in line with schedule 2 & 4 (6) DS0000015079.V264958.R01.S.doc Version 5.0 Page 25 3 4 5 YA9 YA20 YA34 Westfield Road (1) 6 YA42 A system should be put in place for checking the first aid box contents. Westfield Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Road (1) DS0000015079.V264958.R01.S.doc Version 5.0 Page 27 - 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. 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