Inspection on 18/05/05 for Westgate

This inspection was carried out on 18th May 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 no outstanding requirements from the previous inspection report, but made 101 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 01/11/05

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 18 May 2005 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 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 Stationary 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 E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westgate Address 60 Edward Street West Bromwich West Midlands. B70 8NU 0121 580 0196 Telephone number Fax number Email 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 Ltd. Care Home 7 Category(ies) of LD Learning Disability (7) registration, with number of places Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th January 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 E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at the home at 10am and stayed until 8pm. Most of the inspector’s time was spent looking at Requirements identified in previous inspections to see how the home was progressing to meet these. The inspector did however, spend time talking to service users, interviewing staff, observing practices and looking around the building. There has been an Acting Manager in post at the home since August 2004 who previously worked at another home within the organisation. This person does not intend to put forward an application to be registered and does not have any experience of the client group living at the home. By the end of the visit the inspector was concerned with the high number of outstanding Requirements, additional Requirements identified during the visit and no evidence that a permanent manager had been recruited. These issues pose risks to the people living at the home. An action plan was agreed whereby an additional three monitoring visits will take place in order to ensure action is progressed within agreed timescales to address Requirements and concerns, and to attempt to prevent enforcement action being taken. What the service does well: What has improved since the last inspection? Staff said that they had been on lots of courses that help them to care for the people living at the home. Recording systems need improvement so that training is arranged equally for everyone. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 6 People living at the home said that the food is much better than it used to be; again records need to be improved that show people are offered daily choices. Although people said that activities take place all staff that were interviewed commented that these could be improved if the home had its own transport. 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 E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 5. Further work must be undertaken to ensure prospective service users are given information about services provided by the home. The pre-admission assessment process must be developed to ensure prospective service users aspirations and needs are fully met. EVIDENCE: The home has a Statement of Purpose and Service User Guide that are maintained at the entrance to the home, in addition to this each service user has a copy of the Guide in their bedroom. The Statement of Purpose was reviewed in June 2004 and contained details of the Acting Managers qualifications. It was noted by the inspector that this information states that the Acting Manager holds NVQ levels 2,3 and 4 in care when she does not. No progress had been made by the home to produce a Service User Guide in a suitable format for the people who live at the home and prospective residents. The inspector could find no evidence of the home’s needs assessment tool having being reviewed or that service users have been informed in writing that the home is suitable for the purpose of meeting their individual needs (Requirements identified in previous inspections). The inspector instructed that this should be given urgent attention as one service user is due to move from the home and potential new people will require assessing. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 9 Three service user files were sampled and none contained contracts detailing terms and conditions of residency. The inspector was informed that these had been removed by senior management within the organisation but could not be told a reason why. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 8 and 9. Care planning is not consistent and therefore does not always provide staff with the information they need to satisfactorily meet service users needs. The systems for service user consultation in this home are poor with little evidence that indicates that service users views are both sought and acted upon. EVIDENCE: The inspector sampled three service user files, none of which contained all of the primary care needs of individuals and information stating how the home will support individuals to ensure these will be met. Discussion with staff suggested that some needs were being addressed even though there is a lack of clear plans and guidance. This approach is dependent on staff memory and good verbal communication systems. Service users are at risk of not having their care needs met if these informal systems break down. In addition to this only one contained evidence that demonstrated six monthly multi-disciplinary reviews taking place (these Requirements remain outstanding from previous inspections). The inspector was particularly concerned about the lack of evidence that multidisciplinary reviews taking place for one service user due to leave the home in approximately two weeks time as no evidence of an appropriately managed transition could be found. The staff and manager also raised concerns about this person moving on, stating that the social worker Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 11 had not obtained their views and knowledge of the needs of the individual concerned and that the service user had only undertaken one visit to the new placement. The inspector instructed that the home should put their concerns in writing to the social worker and forward a copy of the letter to the CSCI. All staff interviewed stated that monthly residents meetings take place in order that service users can be involved in making decisions about their lives and participate in choices relating to the home and the environment. Records did not substantiate that meetings occur monthly and no evidence could be found that decisions made in response to residents requests in these meetings had been actioned (this Requirement remains outstanding from a previous inspection). Each service users file sampled contained risk assessments for various aspects of their care such as outings, behaviour and equipment, however the home currently uses three different formats some of which do not identify how the home intends to manage risks and were not comprehensive in content. The inspector also found that not all staff had knowledge of the service users risk assessments and no evidence that service users are involved in their compilation. The Acting Manager did state that they are discussed with individuals however no evidence was available to verify this. Previous Requirements relating to risk assessments remain outstanding. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 standard(s) 13, 14 and 17. The home has made very limited progress to improved systems that would support and enrich service users social and educational opportunities. Records do not demonstrate that the home provides a varied menu that enables service users to exercise choice and control over what they eat. EVIDENCE: Staff confirmed that service users undertake a variety of activities both inhouse and external. These have included board games, watching television, visits to the pub, discos and daytrips. They stated that group activities are restricted due to the home having no transport of its own. The home can access a mini-bus owned by the organisation however times of use are restricted. No progress has been made to address Requirements identified in a previous inspection relating to activity budgets, transport and policies and procedures. The inspector found that activities are presently recorded in three separate documents. This is resulting in confusion and not all activities are being recorded and evaluated. The inspector was informed that three service users did not go on holiday last year but that the home was looking into possibilities of a holiday in Crete in Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 13 September this year. The inspector instructed that the Commission for Social Care Inspection must be provided with documentary evidence that this occurs, including who pays for staff to escort service users. All service users that the inspector spoke to stated that the food is good at the home. During the day the inspector observed service users being offered choices at lunchtime however when examining menus these did not detail alternatives particularly in relation to hot meals (this Requirement remains outstanding from a previous inspection). Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20 and 21. Service users are potentially at risk due to their health needs not being assessed, monitored, recorded and met in full. Medication practices do not encourage independence, within a risk management framework. EVIDENCE: Service users health records are not being recorded and monitored in full potentially placing individuals at risk (this Requirement remains outstanding from a previous inspection). For example one service users file stated that they had visited the Doctor in July 2004 and that a referral to the incontinence nurse must be made, however no evidence of this taking place could be found. All files sampled contained Initial Health Assessments but none had been recorded in full or had action plans completed. Also two service users have specific dietary needs but no nutritional screening and assessments have been completed. The inspector asked staff if anyone living at the home manages or administers their own medication. Everyone stated that this did not take place, giving reasons such as, “they might overdose” and “they might forget to take it”. The inspector could find no evidence that assessments had been completed that substantiated these comments. The inspector sampled five staff training files and found none contained evidence that staff have undertaken accredited Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 15 medication training. The acting manager stated that staff were in the process of obtaining this qualification but had not yet completed. Since being last inspected the home has reviewed the policy of ageing and death to include care of the dying and support for service users and staff. No files sampled contained evidence that the home had obtained the views and wishes relating to funeral arrangements from service users and/or their representatives. The inspector acknowledges that this can be a distressing subject, but one that must be addressed by the home to ensure a holistic care package is maintained. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 16 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 standard(s) STANDARDS NOT ASSESSED AT THIS INSPECTION. EVIDENCE: Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24, 25, 27, 28 and 30. The standard of decoration and furnishings in parts of the home is poor with little evidence of improvement through maintenance and future planning. The home does not, therefore, present a homely and comfortable environment as it could for service users. EVIDENCE: Since last being inspected the many service users bedrooms have been painted and a new suite purchased. Only four of the twelve Requirements identified in previous inspections have been actioned resulting in many areas of the home either appearing worn or posing risk to individuals. In addition to this several further areas require attention around the home: * The cigarette nubs must be cleared from the garden and an appropriate disposal system introduced. * The old suite must be removed from the garden * Blinds must be fitted in the conservatory to ensure privacy. * The curtains must be replaced in the lounge, as they do not fit. * The flooring must be replaced in the staff toilet, as there is a large gap at the rear of the toilet allowing fluids to seep underneath Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 18 * The sink in the laundry that is used to sluice soiled articles must be replaced as the enamel has become worn and poses a risk of infection * The build up of lint and objects behind the dryer must be addressed as a mater of urgency due to the risk of fire. * All laundry bins require lids to reduce the risk of cross-contamination. * Any worn bedding must be replaced * The walls in the kitchen must be cleaned (paying particular attention to the stains around the top of the walls. * The extractor fan in the kitchen requires repairing or replacing if it cannot be repaired. * The downstairs toilet requires decorating as it is stained and worn. The toilet seat must also be replaced due to the build up of rust and excrement. * Any service user who has incontinent needs must have waterproof bedding provided. * The rusty handrail in the bathroom must be replaced. * The shower cubicle in the bathroom must be cleaned and stains removed. * Bedrooms 3 and 6 must have curtains or blinds fitted that ensures privacy from neighbouring home. * All shared soap located in kitchen, toilets and bathrooms must be of the liquid variety to ensure infection control standards are maintained. * Assessments must be completed that show service users have been offered a key to their bedroom and demonstrate if not offered, why not. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. Positive relationships have been formed between the staff and service users creating an inclusive and open atmosphere. Staff need further training and support in order to meet the assessed needs of people living at the home. EVIDENCE: Staff that the inspector interviewed demonstrated various levels of knowledge relating to the needs of service users and confirmed they had undertaken courses including Adult Protection, Crisis Prevention Intervention, NVQ’s and mandatory training such as fire, first aid and manual handling. The inspector was therefore disappointed when checking staff records as none of the four files sampled contained certificates that substantiated these comments. Staff also stated that they undertake induction and Learning Disability Award Framework accredited training but again no evidence of this could be found. No staff at the home have undertaken communication training specific to the needs of people living there or equal opportunities training. All staff files contained profiles and individual training plans but none had been completed in full resulting in ineffective monitoring. In previous inspections the staffing levels have been disputed. No evidence of assessment levels agreed with placing authorities could be found on service users files and the staffing ratios determined by the home were found not to Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 20 be maintained at all times. The Commission for Social Care Inspection had not been informed when these situations occurred as instructed in a previous inspection. The inspector also instructed that rotas must be expanded to demonstrate how many service users are at home throughout the day in order to monitor ratios and that time spent on domestic duties must be clearly highlighted as the home does not employ separate domestic staff. Some progress has been made to ensure all staff files contain the required documentation as listed in Schedules 4 and 6 of the Care Homes Regulations 2001. However the inspector was disappointed that documentation for one member of staff who previously worked within another establishment owned by the organisation was still not retained within the home and that not all files contained a photograph of individuals. The inspector also raised concerns that one member of staff did not have a CRB disclosure. Service users that the inspector spoke to stated that they are not involved in choosing who is employed at the home with one person stating, “I don’t know who does it, they just turn up”. All staff that the inspector spoke to stated that they had received a supervision session with the Acting Manager and that they found this support useful. Staff also stated that they had never received an annual appraisal, with some not sure what this would entail. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41, 42 and 43. The management of this home is poor, with inconsistent practices in areas of monitoring records, which could potentially place people at risk. There is very little evidence that the home regularly reviews its performance, resulting in deterioration in service provided to people. EVIDENCE: All staff interviewed spoke highly of the Acting Manager with one person stating, “It’s a nice place to work since she has been here”. The Acting Manager does not hold either a NVQ level 4 in care or the Registered Managers Award and has no experience of learning disabilities and will not be putting forward an application to be registered. The inspector instructed that the organisation must address recruiting a permanent manager as a matter of priority. The home has still to implement a quality assurance system. The inspector was shown such a system but found that this had only been completed in part Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 22 and did not evidence that the views of service users, their families and other interested parties had been sought. The inspector was concerned that previous Requirements to develop the homes restraint policy had not been addressed. If put into practice the present policy puts service users at risk and does not comply with legislation. The inspector found it very difficult to ascertain if staff have undertaken training in food hygiene, first aid, moving and handling, health and safety, infection control and fire due to poor recording systems (see Standard 32 and 35) and therefore Requirements relating to training remain outstanding. The Acting Manager did state that five of the eleven staff that work at the home are due to undertake a food hygiene examination on 29th May 2005. When looking around the building the inspector found that the food cupboard in the kitchen is kept locked and was informed that this was due to, “food going quickly” and “knifes being stored in there”. The inspector instructed that the home must complete a written assessment of this practice and look at alternatives that do not restrict service users freedom of choice whilst maintaining their safety. A risk assessment must also be completed for the gate that has the potential to restrict service users movements, located at the bottom of the stairs. A number of Requirements identified in previous inspections (see Requirements section at back of this report) relating to health and safety remain outstanding and must be addressed as a matter of urgency. No progress has been made to provide a business plan, a copy of the homes audited accounts and policies relating to financing the cost of staff entrance fees when accompanying residents on activities. A meeting with the Registered Providers is to take place to discuss these Requirements and others that require their involvement. Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 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 2 x x 1 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x 2 2 x x Standard No 11 12 13 14 15 16 17 x x 2 2 x x 2 Standard No 31 32 33 34 35 36 Score 3 2 1 2 1 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westgate Score x 1 2 2 Standard No 37 38 39 40 41 42 43 Score 1 x 1 2 2 1 2 E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 24 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 Acting Managers qualifications must be amended in the Statement of Purpose The home must review the needs assessment tool to ensure it meets all of standard 2.3 of the National Minimum Standards (REQUIREMENT ORIGINALLY MADE MAY 2002) The registered person must confirm in writing to each service user that having regard to the assessment the care home is suitable for the purpose of meeting their individual needs in respect of health and welfare (REQUIREMENT ORIGINALLY MADE MAY 2002) All residents must sign Terms and Conditions/contracts and/or their representatives and copies must be issued (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The home must develop service users care plans in order that they clearly detail the primary Timescale for action 07/06/05 2. 3. YA1 YA2 4,5,6 14 01/07/05 07/06/05 4. YA2 14 07/06/05 5. YA5 5(1)(b) 07/06/05 6. YA6 15 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 25 7. YA6 15 8. YA6 15 9. YA6 15 10. YA6 15 11. YA6 15 12. YA7 12(2) 13. 14. YA7 YA8 12(2) 12(2) care needs and (as listed in Standard 2) and how these can be supported (REQUIREMENT ORIGINALLY MADE MAY 2002) All residents must have sixmonth multi-disciplinary review meetings to review their plan of care. Minutes must be taken and retained (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The home must put in writing its concerns about the service user who is due to move from the home to the relevant social work team and a copy of this letter must be forwarded to CSCI The home must be able to demonstrate that service users are involved in the monthly keyworker meetings 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) Domestic tasks wich residents want to learn to achieve personal aspirations must be included in the plan of care, actioned and monitored (REQUIREMENT ORIGINALLY MADE MARCH 2004) Decisions made in response to residents requests and agreed at residents meetings must be carried through or reasons for not doing so must be documented (REQUIREMENT ORIGINALLY MADE JANUARY 2004) Residents meetings must occur monthly with records maintained The home must involve service users in the day-to-day running of the home, and development and review of its policies and 07/06/05 01/06/05 01/10/05 07/06/05 07/06/05 07/06/05 01/10/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 26 15. YA8 12(2) 16. YA9 13(4) 17. YA9 13(4) 18. YA9 13(4) 19. YA9 13(4) 20. YA13 16(2) 21. YA13 16(2) 22. YA13 16(2) procedures (REQUIREMENT ORIGINALLY MADE MAY 2002) The home must be able to demonstrate that service users are involved in the recruitment and selection of staff Any risk assessment format used in the home must be comprehensive and identify how the home intends to manage and/or reduce risk. The assessment must relate to individual service users and their care plan (REQUIREMENT ORIGINALLY MADE MAY 2002) Staff must sign all risk assessment to indicate knowledge and understanding (REQUIREMENT ORIGINALLY MADE JANUARY 2004) Residents must be included in the process of risk assessment appertaining to them and must be given the opportunity to sign to evidence participation (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The manager must undertake risk assessment training (REQUIREMENT ORIGINALLY MADE MARCH 2004) Records must demonstrate that levels of activity offered to residents have increased (REQUIREMENT ORIGINALLY MADE JANUARY 2004) A budget must be established to meet the costs incurred by staff when attending leisure activities with residents (REQUIREMENT ORIGINALLY MADE JANUARY 2004) A policy and procedure must be developed to enable the manager to access funding to ensure community activities are undertaken (REQUIREMENT ORIGINALLY MADE JANUARY 01/10/05 07/06/05 07/06/05 07/06/05 07/06/05 07/06/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 27 2004) 23. YA13 16(2) The transport needs of each resident must be assessed and recorded on file. Action must be take to ensure that these needs are met to ensure to option of community access is availible for all residents (REQUIREMENT ORIGINALLY MADE JANUARY 2004) Service users in long-term placements must have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help to choose and plan (REQUIREMENT ORIGINALLY MADE MAY 2002) The home must provide evidence to the Commission for Social Care Inspection that the provider is funding holidays and short breaks as per the homes Statement of Purpose (REQUIREMENT ORIGINALLY MADE JULY 2004) The Commission for Social Care Inspection must be supplied with documentary evidence detailing who pays for staff to escort service users on holiday There must be alternatives included on the menu. Residents who decline the hot menu option must be provided with the option on an alternative hot meal (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The home must review how it obtains fresh mild to ensure the home is well supplied (REQUIREMENT ORIGINALLY MADE JULY 2004) Nutritional assessments must be completed for all service users All health screening must be offered to all residents (optical, 07/06/05 24. YA14 16(2) 07/06/05 25. YA14 16(2) 07/06/05 26. YA14 16(2) 01/10/05 27. YA17 16(2) 07/06/05 28. YA17 16(2) 07/06/05 29. 30. YA17 YA19 16(2) 12(1) 01/10/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 28 31. YA19 12(1) 32. 33. YA19 YA19 12(1) 12(1) 34. YA20 13(2) 35. YA20 13(2) 36. YA20 13(2) 37. YA21 12(1) 38. YA24 16(1) 39. YA24 16(1) testicular and hearing screening is overdue) (REQUIREMENT ORIGINALLY MADE JANUARY 2005) Medical advice in relation to a residents tumour history must be sought to clarify if there is any further screening required (REQUIREMENT ORIGINALLY MADE JANUARY 2005) Initial health assessments must be completed in full and action plans agreed The home must ensure prompt referrals are made to appropriate specialists e.g incontinence and speech and language All residents must be offered the opportunity of an annual medication review (REQUIREMENT ORIGINALLY MADE JANUARY 2005) Staff who administer medicines must complete accredited medication training(REQUIREMENT ORIGINALLY MADE JANUARY 2004) The home must support service users to retain, administer and contol their own medication within a risk management framework Service users and/or their representatives views and wishes must be sought about funeral arrangements and effects after death The home must produce a rolling programme of redecoration throughout the environment and include timescales for action (REQUIREMENT ORIGINALLY MADE MAY 2002) The carpet in the lounge must be replaced (REQUIREMENT ORIGINALLY MADE JANUARY 2004) 07/06/05 01/10/05 01/10/05 07/06/05 07/06/05 01/07/05 01/10/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 29 40. YA24 16(1) 41. YA24 16(1) 42. YA24 16(1) 43. YA24 16(1) 44. 45. 46. 47. YA24 YA24 YA24 YA25 16(1) 16(1) 16(1) 16(1) 48. YA26 16(1) 49. 50. YA26 YA26 16(1) 16(1) 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 2004) The temperature of J.J bedroom must be monitored and recorded twice daily and must not fall below the required temperature range (REQUIREMENT ORIGINALLY MADE MARCH 2004) The home must devise and implement a written programme of renewal for basins and vanity units with target dates according to identified priority (REQUIREMENT ORIGINALLY MADE JULY 2004) The cigarette nubs must be cleared from the garden and an appropriate disposal system introduced The old suite must be removed from the garden Blinds must be fitted in the conservatory The curtains must be replaced in the lounge If a vacancy becomes available in the shared room, the remaining occupant must be given the option of a single room(REQUIRMENT ORIGINALLY MADE JULY 2004) Assessments must be completed that show service users have been offered a key to their bedroom and demonstrate if not offered, why not Bedrooms 3 and 6 must have curtains or blinds fitted that ensure privacy Any service user who has incontinent needs must have water proof bedding 07/06/05 07/06/05 07/06/05 07/06/05 01/07/05 01/07/05 01/07/05 07/06/05 01/10/05 01/07/05 01/07/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 30 51. 52. 53. 54. YA26 YA27 YA27 YA27 16(1) 16(1) 16(1) 16(1) Worn bedding must be replaced The flooring must be replaced in the staff toilet The downstairs toilet requires decorating and cleaning. The toilet seat must be replaced Curtains must be provided in the first floor bathroom (REQUIREMENT ORIGINALLY MADE MARCH 2004) The lock on the ground floor toilet door must be changed (REQUIREMENT ORIGINALLY MADE JULY 2004) The rust handrail in the bathroom must be replaced The walls in the kitchen must be cleaned (paying particular attention the the stains around the top of the walls) The extractor fan in the kitchen requires repairing or replacing if it cannot be mended The sink in the laundry must be replaced The build up of lint and objects behind the dryer must be removed All laundry bins require lids The home must only provide liquid soap for communal use in kitchen, toilets and bathrooms Staff must be provided with makaton training in sufficient numbers to ensure that there is a staff member on duty at all times who can communicate with R (REQUIREMENT ORIGINALLY MADE MARCH 2004) All staff must hold a care NVQ level 2 or 3 or be working to obtain one by an agreed dates, with certificates maintained in the home for inspection Staffing ratios must be maintained at all times (1 senior plus 3 support workers) 01/08/05 01/08/05 01/07/05 07/06/05 55. YA27 16(1) 07/06/05 56. 57. YA27 YA28 16(1) 16(1) 01/07/05 01/07/05 58. 59. 60. 61. 62. 63. YA28 YA30 YA30 YA30 YA30 YA32 16(1) 13(3) 13(3) 13(3) 13(3) 18(1) 01/07/05 01/10/05 07/06/05 01/07/05 01/07/05 07/06/05 64. YA32 18(1) 01/10/05 65. YA33 18(1) Immediate Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 31 66. YA33 18(1) 67. YA33 18(1) 68. YA33 18(1) 69. 70. YA33 YA34 18(1) Schedules 4, 6 Schedules 4, 6 71. YA34 72. YA34 Schedules 4, 6 73. YA34 19 (REQUIREMENT ORIGINALLY MADE MARCH 2004) The Commission for Social Care Inspection must be informed on each occasion that staffing levels are not met (as a Regulation 37 notice) (REQUIREMENT ORIGINALLY MADE July 2004) The provider following reassessment of need must cofirm in writing to the Commission for Social Care Inspection the agreed minimum staffing levels for each resident and the minimum numbers of staf to be provided on each shift (REQUIREMENT ORIGINALLY MADE JULY 2004) The staff rotas must be expanded and include details of when service users are out of the home and time spent on domestic duties A minimum of six staff meetings must every year that are recorded and actioned Photographs of staff members must be held on their personnel file (REQUIREMENT ORIGINALLY MADE JULY 2004) All documentation relating to the indentification of applicants for employment must be obtained and be on file prior to the commencement of employment (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 (REQUIREMENT ORIGINALLY MADE JULY 2004) A enhanced CRB/POVA declaration must be obtained for P and a risk assessment completed until this is in place Immediate 07/06/05 01/07/05 01/10/05 07/06/05 07/06/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 32 74. YA35 18(1) 75. YA35 18(1) 76. YA35 18(1) 77. 78. YA35 YA35 18(1) 18(1) 79. YA36 18(2) 80. 81. YA36 YA37 18(2) 9(2) 82. YA37 9(2) 83. YA37 9 The home must be able to demonstrate that all new staff undergo foundation training (to NTO specification) within six months of employment (REQUIREMENT ORIGINALLY MADE MAY 2002) All staff must be provided with equal opportunities training (REQUIREMENT ORIGINALLY MADE MAY 2002) The home must have a training and development plan and a designated person responsible for training and development Staff profiles and individual training plans must be completed in full The home must be able to demonstrate that staff use Learning Disability Award Framework accredited training All staff must receive a minimum of six supervision sessions a year. The manager must also receive regular supervision (REQUIREMENT ORIGINALLY MADE MAY 2002) All staff must receive an annual appraisal The manager must undertake the Intermediate Food Hygiene Award (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The manager must have easy access to a photocopier in order to fulfil her duties in respect of records to be held (REQUIREMENT ORIGINALLY MADE MARCH 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) 07/06/05 07/06/05 01/10/05 01/10/05 01/07/05 07/06/05 01/10/05 07/06/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 33 84. YA39 24 85. YA39 24 86. YA39 24 87. YA39 24 88. YA39 24 89. YA40 Schedules 1,4 90. YA40 Schedules 1,4 91. YA40 Schedules 1,4 Schedules 1.4 13(3-6) 92. YA40 93. YA42 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 The results of service user surveys must be published and made available to service users and other interested parties including CSCI The views of families, friend, advocates and stakeholders in the community must be sought on how the home is achieving goals Action must progress within agreed timescales to implement requirements identified in CSCI inspections The homes restraint policy must be reviewed to ensure that it complies with legislation (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The homes restraint policy must be expanded to define the exceptional circumstances in which physical restraint would be used ensuring legal compliance and stating that it would only be used as a last resort (REQUIREMENT ORIGINALLY MADE JANUARY 2004) The homes restraint policy must detail agreed and banned holds (REQUIREMENT ORIGINALLY MADE JANUARY 2004) Policies must state the reasons for challenging behaviour (REQUIREMENT ORIGINALLY MADE JANUARY 2004) Ensure all staff receive training in infection control, food hygiene, first aid, moving and 07/06/05 01/10/05 01/10/05 01/10/05 01/10/05 07/06/05 07/06/05 07/06/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 34 94. YA42 13(3-6) 95. YA42 13(3-6) 96. YA42 13(3-6) 97. YA42 13(3-6) 98. YA42 13(3-6) 99. YA42 13(3-6) 100. YA43 25 101. YA43 25 handling and fire safety, with certificates maintained (REQUIREMENT ORIGINALLY MADE MAY 2002) COSHH assessments must be updated and signed by all staff (REQUIREMENT ORIGINALLY MADE JANUARY 2004) An electric socket in the shared bedroom is fitted with a multi socket adapter that is used to its capacity. The manager is required to seek advice from Environmental Health Department about this practice and to implement any advice given (REQUIREMENT ORIGINALLY MADE JULY 2004) Risk assessments must be carried out for and with individual staff members if there is concern about the effect of working hour on that individual staff member (REQUIREMENT ORIGINALLY MADE JULY 2004) Risk assessments must be carried out for all safe working practice topics covered in Standards 42.2 and 42.3 of the National Minimum Standards A risk assessment must be completed for the practice of locking the food cupboard and alternative practices explored A risk assessment must be completed for the use of the gate located at the bottom of the stairs in the house A copy of the homes business plan and audited accounts must be forwared to the Commission for Social Care Inspection (REQUIREMENT ORIGINALLY MADE MARCH 2004) Evidence must be sent the the Commission for Social Care Inspection that the home has developed a policy and 07/06/05 07/06/05 07/06/05 01/07/05 01/07/05 01/07/05 07/06/05 07/06/05 Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 35 procedure for financing the costs of staff entrance costs when accompanying residents on activities in the community and developed a budget to meet these costs (REQUIREMENT ORIGINALLY MADE MARCH 2004) 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. 4. Refer to Standard YA9 YA13 YA14 YA35 Good Practice Recommendations Consideration should be given to only using one format for the risk assessment process It is recommended that the home purchases its own transport Consideration should be given to only using one format for recording and evaluating activities (both inhouse and external Consideration should be given to expanding the individual training and development plans as presently they do not allow for developmental needs that do not require formal training to be recorded Westgate E55 S4827 Westgate V228430 180505 Stage 4.doc Version 1.30 Page 36 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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. 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