Inspection on 01/11/05 for Westgate

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 37 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westgate 02/07/07

Westgate 21/04/06

Westgate 18/05/05

Westgate 25/01/05

Westgate 23/07/04

Westgate 18/03/04

Westgate 06/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Westgate 60 Edward Street West Bromwich West Midlands B70 8NU Lead Inspector Lesley Webb Unannounced Inspection 1st November 2005 09:20 Westgate DS0000004827.V260095.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 Westgate DS0000004827.V260095.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. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westgate Address 60 Edward Street West Bromwich West Midlands B70 8NU 0121 580 0196 NONE 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) Swan Village Care Services Limited Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 May 2005. Brief Description of the Service: Westgate is a privately owned home which has been registered to provide personal care for a maximum of seven adults who have learning disabilities. Including Westgate, Swan Village Care Services Limited operates several other care homes in the West Midlands. Westgate is a converted Victorian house situated on Edward Street. Edward Street is currently one way and located within easy travelling distance of West Bromwich town centre. There is easy access to all local amenities such as a shopping centre, library, college, churches and leisure facilities, which provides service users with the opportunity to lead active lives within the community. Parking is restricted to permits only but Westgate has permits available for visitors to the home. The home is accessed via the main entrance at the front of the property. There is one double bedroom and five single bedrooms. There is a long garden to the rear, which contains garden furniture for the use of service users. Currently the dining room/conservatory is a designated smoking area. On the second floor, there is a self-contained flat and office for staff use. The home does not provide any lift facilities and therefore would not be suitable for a service user with mobility difficulties. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 9.20am and stayed until 5.15pm. During the visit time was spent talking to service users (2 in private), interviewing 4 staff, looking at records and observing care practices before giving feedback about the inspection to the acting manager. This is the second inspection to take place at the home this year and therefore both this report and the one published in May should be read when looking at information regarding the home. In addition to the 2 unannounced inspections 3 monitoring visits have been undertaken to the home due to the high amount of outstanding requirements identified in previous inspections resulting in areas of concern. In total 79 of the 101 requirements have now been fully met, 7 part met and 15 remain outstanding. By addressing the majority of requirements the inspector is satisfied that people living at the home now receive a better service. . However as the home still to submit an application to register the manager and to implement a quality assurance system and because of the requirements identified in this inspection a further 2 monitoring visits have been arranged to check that the quality of service provided to residents does not deteriorate. The inspector would like to thank service users and staff for their co-operation and assistance during the visit, where she was made to feel very welcome. What the service does well: The home has a very welcoming and friendly atmosphere. Service users and staff all stated that this encourages the families of service users to visit. For example one person stated, “Its important that people feel comfortable to visit their relatives, we always try to involve them and make them feel relaxed”. Records are maintained ways that promote service users confidentiality. All staff that were interviewed demonstrated knowledge in this area, explaining who has the right to information about service users and where information should be stored. Throughout the visit staff were seen to treat service users with respect and dignity, respecting their wishes whilst encouraging them to make choices according to their abilities. All the service users that were spoken to named various staff that they felt happy to talk to if they had a problem or wanted to complain. They also stated that they were confident that any issues they are always dealt with. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Westgate DS0000004827.V260095.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 Westgate DS0000004827.V260095.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): 1, 3 and 4. The home’s statement of purpose and introductory visits to the home are adequate, enabling prospective service users to make choices about where they live. The home is not meeting all the needs of people who live there, if allowed to continue this could affect their quality of life. EVIDENCE: A previous requirement to produce the service user guide in an alternative format remains unmet. The acting manager however, did state that the home was now in receipt of video equipment in order that this will be actioned. The service user group living at the home have a variety of differing needs including medical, religious and social. When looking at care plans and other records the inspector found that in the main the home is meeting these needs. However one service user care plan and activity timetable states that they wish to attend church but no evidence of this occurring could be found. Also another service users documentation states that they are diabetic and epileptic but staff at the home have not undertaken training for either of these. The inspector asked staff, “how can you be sure you can meet the needs of people when they move into the home?” Everyone demonstrated knowledge in this area with responses including, “by making sure threes a care plan drawn up prior to admission, being able to communicate, talking to families and social workers”. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 9 The skill mix of staff working at the home is varied and complements the people living at the home. The acting manager stated that there is a rolling programme where staff undertake communication training in order to communicate effectively with service users. The home also uses a local advocacy service to support people with decision-making. There is a comprehensive policy and procedure regarding introductory visits to the home that covers all of standard 4 of the national minimum standards. When interviewing staff no one was able to give any details of the contents of this policy. One of the service users that the inspector spoke to confirmed that they had visited the home prior to moving in stating, “I came and had a look around, met the staff and other people who live here. One of them gave me a kiss and hug when I was leaving and said bye, I thought that was nice”. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 10 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 and 10. Although improvements to care planning have been made over the last 12 months, further work is still required in order that service users can be satisfied that their needs will be met in full. Information is stored correctly in this home, ensuring service users rights to confidentiality are maintained. EVIDENCE: Previous requirements to expand care plans so that they cover all aspects of personal, healthcare and social support have now been met. However requirements relating to daily records correlating to care plans and evidencing service users involvement in monthly key worker meetings still require attention. The acting manager agreed that a training session would be arranged for staff to address these. Documentation relating to staff and service users is stored confidentially, with files containing general information open to access by all staff and information of a sensitive nature kept in a locked cabinet with access only through the manager. The home has policies and procedures on confidentiality and data protection. When looking at these the inspector found that only 3 staff who Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 11 work at the home having signed to state they have read and understood. All staff that were interviewed were able to explain their roles and responsibilities in relation to promoting service users confidentiality as well as demonstrating knowledge of the homes policy on confidentiality. An example of this is, “if people talk to me I must promote confidentiality unless it endangers someone’s wellbeing. If I have to inform someone else I would discuss this with the service user first. Disciplinary action can be taken if you breech the confidentiality policy”. Westgate DS0000004827.V260095.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): 11, 12, 15 and 16. Generally care planning has improved since the last inspection, now providing staff with adequate information in order that they can support service users to develop personally. The atmosphere within the home is friendly and welcoming towards visitors, creating an inclusive place for residents to live. Policies and practices regarding smoking in this home are poor, failing to promote the wellbeing and rights of service users. EVIDENCE: Since the last inspection care plans have been implemented for emotional, communication and independent living skills in order that personal development needs can be addressed and monitored. When sampling these the inspector found that 2 of the 3 service users plans for promoting independent living skills had not been reviewed since July 2004. As previously mentioned in standard 3 some service users at the home are not being supported to fulfil their spiritual needs. The acting manager recognises that improvements are required and agreed this would be given priority. Staff confirmed their understanding of supporting service users. For example one Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 13 person stated, “We are here to encourage to participate in everyday things. Someone might not like house work but we encourage and explain how to do things” and another “try and get them to help make their own meals, guide them through it”. All but one service user attends day placements including college, daycentres and work placements in order to take part in valued and fulfilling activities. One of the service users informed the inspector that they “work at a printers and I get paid £10 a week for 2 days work. I make cards, leaflets and lots of other things, it’s alright there”. A member of staff informed the inspector when being interviewed that the service user who does not attend day care likes to read and write and do puzzles, however when looking at the care plan for this individual nothing could be found that demonstrates staff support or spend time supporting the service user with this. Also since the last inspection care plans have been introduced to support service users to maintain links with family and friends. In addition to this the home has a visitors and relationships policy and procedure that support practices within the home. Several service users confirmed that their families visit the home. In addition to this one service user informed the inspector that they have a mobile phone in order that they can talk to their mother in private whenever they choose. Practices observed throughout the inspection demonstrated that the daily routines and house rules generally promote independence and freedom of movement. Where restrictions do apply such as a kitchen cupboard being locked for health and safety reasons a risk assessment is in place and alternative choices for service users have been put into place. There is a gate located at the bottom of the stairs in the building that has been put in place to safeguard a particular service user. Risk assessments were found to be in place for all other service users regarding this restriction however none were found to be based on the individual’s needs and capabilities. Service users that the inspector spoke to all stated that they open their own mail, have a key to their bedroom and that they can choose what time they get up or go to bed. One service user added, “I was still in bed at 2.30 one day so a member of staff came and knocked on my door to see if I was alright and going to get up”. When interviewing staff the inspector asked, “what do you know about service users rights and responsibilities? How do these affect your role?” A variety of responses were made including, “they have equal rights as anyone else. As a carer I have a responsibility to ensure their needs are met and they have choices but if they refuse to participate in something such as personal hygiene I must explain what could happen if they refuse but I cannot force them”. Another response was, “it’s their right to smoke but they haven’t the money to smoke like staff. We have to explain this”. The inspector examined care plans in place for service users that smoke and found that these detailed how staff Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 14 should support individuals. The inspector was therefore concerned when staff were observed smoking in the dining area (this being the designated smoking area for service users) in front of service users whose smoking was being restricted. In addition to this the door leading to the lounge was open allowing smoke to escape to other areas of the home where non-smokers were sitting. The inspector discussed this practice with the acting manager and service coordinator, both of which agreed this was not acceptable. Westgate DS0000004827.V260095.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 and 19. Personal support in this home is offered in such a way as to promote and protect service users dignity and independence. The health needs of service users are well met with evidence of good multi disciplinary working taking place, on a regular basis. EVIDENCE: The inspector asked staff, “how do you make sure your giving personal support in the way that is needed and wanted by a service user?” All staff that were interviewed demonstrated knowledge in this area. Responses included, “by following care plans, talking to clients and giving choices” and “ reading care plans and talking to service users, staff and the manager”. Practices observed throughout the visit confirmed that service users are given personal support in a sensitive and respectful manor. All requirements relating to service users physical and emotional health needs have now been met by the home. Although medication was not assessed it was noted by the inspector that all staff that administer medication have either completed or awaiting certification for accredited training. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 16 Westgate DS0000004827.V260095.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): 22 and 23. Generally the home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Generally the arrangements for protecting service users are satisfactory, further work in relation to financial arrangements will reduce the risk of abuse. EVIDENCE: After checking the complaints record the inspector found that no complaints have been made since 2004 however the acting manager has introduced a 3 monthly monitoring system for complaints records which meets the national minimum standards. All service users files sampled contained the complaints procedure in picture format. The inspector recommended that this be reissued to service users as this was originally given several years ago. The inspector asked service users, “if you were unhappy or wanted to complain what would you do?” All service users named people working at the home, including the manager and registered proprietors as individuals they would talk to. All stated that they were happy that these people would “sort things out”. Generally all staff that were interviewed demonstrated some understanding of supporting service users through the complaints process and also of their role in adult protection however, 3 of the 4 staff interviewed stated they did not know the contents of the complaints procedure and had not heard of the whistle blowing policy. The home has comprehensive policies and procedures for adult protection including physical aggression (many of which have been amended since the last inspection). Records also confirmed that the majority of staff working at the home have undertaken both adult protection and physical intervention Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 18 training. After checking records and discussing practices relating to service users finances the inspector instructed that staff be informed of appropriate use. Records demonstrated that service users have been paying for meals from their personal allowances when already funding these as part of their contract price for living at the home. In addition to this the inspector instructed that an audit of the past twelve months personal allowance sheets must take place with full reimbursement made to service users. It was also noted that one service users finances did not balance with the corresponding personal allowance sheet (this was rectified by the manager during the inspection). Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 19 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): 26 and 29. Generally service users bedrooms have furniture and fittings sufficient and suitable to meet individual needs and lifestyles. EVIDENCE: The inspector was invited to view bedrooms by 2 service users. Both were found to be individually decorated and reflected the personal tastes of both occupants. Both service users confirmed that they were happy with their rooms and that they had everything they needed. One service user also gave additional praise stating, “My beds so comfy sometimes I don’t want to get out of it”. It was noted by the inspector that both rooms appeared very full, with items stored on top of wardrobes and on the floor. This was discussed with both service users one of whom said that they thought some shelves would help with storage and the other who informed the inspector that they could not fit anymore clothes in the wardrobe. No service users who live at the home have been assessed as requiring any aids and adaptations however grab rails have been fitted in the bathroom as additional support if required. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 20 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): Not assessed at this inspection. EVIDENCE: Westgate DS0000004827.V260095.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 and 38. Improvements to the management of this home have resulted in better monitoring and implementation of care provided to service users. EVIDENCE: Since the last inspection the home has recruited a manager who has been working at the home and another within the organisation. The acting manager informed the inspector that as of 31/10/05 she was allocated to Westgate only, would be working fulltime supernumerary hours to the care staff and would be submitting an application for registration to CSCI by 1st December 2005. The past 12 months have been very unstable at the home, at times having different management support. When asking staff what the atmosphere at the home is like 3 of the 4 staff interviewed stated that it was good, adding comments including, “its really good. Service users can do what they want” and “its nice, the residents generally get on and staff interact quiet well with the residents”. One member of staff however stated, “its different to what it used to be, there’s no consultation and people are not given choices”. The inspector will be monitoring this during further visits to the home. Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 22 Although not assessed the inspector was shown a quality assurance system that is due to be introduced to the home that has been devised to meet the organisations aims and objectives. The inspector looks forward to assessing this at the next inspection, where it is hoped requirements identified in previous inspections will then be addressed. Westgate DS0000004827.V260095.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 2 X 2 2 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 2 X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 X X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X X X 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westgate Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 1 X X 2 X DS0000004827.V260095.R01.S.doc Version 5.0 Page 24 YES Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4,5,6 Requirement The home must produce a Service User Guide in a suitable format – Requirement originally made May 2002. The home must be able to demonstrate that it can meet the religious needs of service users All staff must undertake diabetic and epilepsy training Staff must be able to demonstrate knowledge of the introductory visits policy The home must be able to demonstrate that service users are involved in the monthly key worker meetings – Requirement originally made May 2005. Staff must be trained in completing monthly key worker reports Daily records for all residents must correlate to the care plan to indicate progress towards the goals set in the care plans – Requirement originally made March 2004. The home must involve service users in the day-to-day running of the home, and development DS0000004827.V260095.R01.S.doc Timescale for action 31/01/06 2 3 4 5 YA3 YA3 YA4 YA6 16(3) 12 18(a) 15 31/12/05 31/12/05 31/01/06 31/12/05 6 7 YA6 YA6 15 15 31/12/05 31/12/05 8 YA8 12(2) 31/01/06 Westgate Version 5.0 Page 25 9 10 11 YA10 YA11 YA12 12 YA16 13 YA16 and review of its policies and procedures – Requirement originally made May 2002. 17(b) All staff must read and sign the homes policies on confidentiality and data protection 15(b) All independent living skills care plans must be reviewed 15 The home must be able to demonstrate that staff support ‘C’ with further education within the home 13(7) Risk assessments for the stair gate must be based on each persons individual needs and capabilities 12, 13, 16 The home must review, implement and monitor that staff comply with the smoking policy. The policy must include: Staff must not smoke in front of non-smoking service users Staff must not smoke in the dining room. A designated area outside of the building must be arranged for staff that smoke When service users who smoke are not doing so staff must not smoke in front of them Service users must not smoke in the dining room when non smoking service users are using this facility The door from the dining room that leads to the lounge must be kept closed when people are smoking A passive smoking policy must be introduced and complied with and the homes smoking policy must work in conjunction with 31/01/06 31/12/05 31/12/05 31/12/05 11/11/05 Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 26 this The homes smoking policies must be forwarded to CSCI 14 YA20 13(2) 15 YA21 12(1) 16 17 YA22 YA23 22(1) 10(1) Staff who administer medicines must complete accredited medication training – part met. Requirement originally made January 2004. Service users and/or their representative’s views and wishes must be sought about funeral arrangements and effects after death – Requirement originally made May 2005. Staff must be able to demonstrate knowledge of the complaints procedure An audit of the last 12 months personal allowance sheets must be completed with service users reimbursed for any breakfast, lunch or dinners they have purchased from their own finances (above the agreed amount contributed by the home). A copy of this audit and findings, along with evidence that service users have been reimbursed must be forwarded to CSCI 31/01/06 31/01/06 31/01/06 30/11/05 18 19 20 YA23 YA23 YA24 10(1) 10(1) 16(1) All staff must be made aware of the homes responsibility to fund service users meals All staff must be issued with a copy of the whistle blowing policy The lighting output throughout the building must be measured and action taken to remedy any non-compliance(Lighting must reach 150 lux) – Requirement originally made January DS0000004827.V260095.R01.S.doc 04/11/05 31/01/06 31/12/05 Westgate Version 5.0 Page 27 2004. 21 YA24 16(1) The home must devise and implement a written programme of renewal or repair for basins and vanity units with target dates according to identified priority – Requirement originally made July 2004. ‘T’ must be assisted to sort the unused items of clothing in his wardrobe with additional storage facilities offered (such as the office on the second floor) Risk assessments must be completed for service users who store items on top of wardrobes and alternative storage facilities explored All documentation relating to the identification of applicants for employment must be obtained and be on file prior to the commencement of employment – part met. Requirement originally made July 2004. All recruitment documentation as detailed in the Care Homes Regulations must be in place at the home prior to the commencement of all staff in employment – part met. Requirement originally made July 2004. All staff must be provided with equal opportunities training – part met. Requirement originally made May 2002. The home must have a training and development plan and a designated person responsible for training and development – part met. Requirement originally made May 2005. The home must be able to demonstrate that staff use Learning Disability Award Framework accredited training – DS0000004827.V260095.R01.S.doc 31/12/05 22 YA26 16(1) 30/11/05 23 YA26 16(1) 31/12/05 24 YA34 4, 6 31/12/05 25 YA34 4, 6 31/12/05 26 YA35 18(1) 31/12/05 27 YA35 18(1) 31/12/05 28 YA35 18(1) 31/12/05 Westgate Version 5.0 Page 28 29 YA36 18(2) 30 YA37 9(2) 31 YA37 9 32 YA39 24 33 YA39 24 34 YA39 24 35 YA39 24 36 YA42 13(3-6) part met. Requirement originally made May 2005. All staff must receive a minimum of six supervision sessions a year. The manager must also receive regular supervision – Requirement originally made May 2002. The manager must undertake the Intermediate Food Hygiene Award – Requirement originally made January 2004. An application to register a permanent, appropriately experienced manager must be submitted to the Commission for Social Care Inspection – Requirement originally made January 2005. Develop and implement a quality assurance tool and ensure that it incorporate the views of service users – Requirement originally made May 2002. The home must implement an annual development plan, based on a systematic cycle of planning, action and review – Requirement originally made May 2005. The results of service user surveys must be published and made available to service users and other interested parties including CSCI – Requirement originally made May 2005. The views of families, friend, advocates and stakeholders in the community must be sought on how the home is achieving goals – Requirement originally made May 2005. Ensure all staff receive training in infection control, food hygiene, first aid, moving and handling and fire safety, with certificates maintained – part DS0000004827.V260095.R01.S.doc 31/01/06 31/01/06 01/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Westgate Version 5.0 Page 29 37 YA43 25 met. Requirement originally made May 2002. A copy of the homes business plan must be forwarded to the Commission for Social Care Inspection – Requirement originally made March 2004. 31/12/05 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 YA13 YA22 Good Practice Recommendations It is recommended that the home purchases its own transport That the complaints procedure be re-issued to all service users Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westgate DS0000004827.V260095.R01.S.doc Version 5.0 Page 31 - 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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