Inspection on 02/07/07 for Westgate

This inspection was carried out on 2nd July 2007.

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

Westgate 21/04/06

Westgate 01/11/05

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 Ms Linda Elsaleh Key Unannounced Inspection 2nd & 3rd July 2007 2:00 Westgate DS0000004827.V337870.R01.S.doc Version 5.2 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.V337870.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V337870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westgate Address 60 Edward Street West Bromwich West Midlands B70 8NU 0121 580 0196 0870 609 2435 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 Munish Kumar Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2006 Brief Description of the Service: Westgate is purchased by Minster Pathway in 2006 and continues to operate as Swan Village Care Services. The home is registered to provide personal care for a maximum of seven adults who have learning disabilities. The building is a converted Victorian house situated on Edward Street. A one-way system is in operation and parking is restricted to residents. Westgate has parking permits which they provide to visitors. The home is situated within easy travelling distance of West Bromwich town centre. There is 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. 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. The dining room/conservatory is a designated a smoking area, during inclement weather. 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. The current weekly fee for this service ranges from £366.48 to £958.00. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 2nd & 3rd July 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address the requirements made at previous inspections. The inspector’s findings are based on the information received by the Commission for Social Care Inspection, examination of relevant records and documents kept at the home and discussions held with staff and service users. Discussions were also held with the manager who was promoted from within the home in September 2006, following the resignation of the previous manager. Some of the requirements and recommendations made in the last inspection report have been addressed and the manager is working on the others. The inspector looks forward to reporting on the progress made at the next inspection visit. The atmosphere within the home was relaxed and friendly and some service users were busy preparing for their forthcoming holiday. Positive comments were received from service users about the care provided. These comments are captured in the overall response given by one of the service users, “I am happy where I am currently living and get along with all the members of staff at Westgate.” Relatives also commented that they considered the care to be “very good” and “service users are well looked after”. What the service does well: The home has produced a revised Statement of Purpose and Service User Guide. Service users continue to be cared for by a stable staff team, the majority of whom hold Level 2 National Vocational Qualifications (NVQ). Staff continue to provide support to service users in maintaining contact with family and friends and arrangements are made for them to participate in some activities in the local community. Arrangements are in place to ensure service users receive regular healthcare checks and medication is appropriately managed on their behalf. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 6 Meal times continue to be flexible and service users are provided with a choice of meals. The home has improved its range of pictorial menus to enable service users to communicate their preferred choices more effectively. What has improved since the last inspection? What they could do better: The assessment procedure for emergency & short-term admissions needs to be reviewed to ensure all care needs are clearly identified, the home is able to meet these needs and appropriate consultation is held with service users. There have been some improvements in the quality of information provided about service users needs. However, more progress is still required in the details included in care plans, risk assessments and daily recordings. Reviews should take place at least once every six months with the service user, their relative/representative and other relevant agencies. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 7 The manager must arrange for all staff to receive an annual appraisal of their work and regular planned supervision. Individual training and development programmes should be produced to support staff to improve their knowledge and skills to ensure they are able to meet the service users needs. Suitable arrangements need to be made during inclement weather for service users who wish to smoke. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 8 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.V337870.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is adequate. Service users are provided with information about the service. However, for service users to be confident their needs will be fully met the home needs to ensure effective consultation takes place and staff are suitably trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the home’s Statement of Purpose & Service User Guide was revised in October 2006. Each service user has a copy of the Service User Guide in their bedrooms and a copy of the contract is available on their files. Service users stated they were provided with information about the home. One service user stated this information was provided by her/his social worker before s/he came to live at the home. At the time of this visit 6 service users were resident. Information provided prior to this inspection stated that no service users had been admitted since the previous inspection. Additional information provided by the home identified that a service user had been admitted during the summer. The service user’s records were available at the home. The current manager stated this was a short-term placement made prior to his appointment and accurate Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 10 information would be provided in the future. The home is advised to review its procedures for assessing the needs of emergency/short notice admissions. The service user shared a bedroom with another who has been resident at the home for some years. There is no documentation to indicate the service users were consulted about sharing a bedroom. Staff said the service users were not compatible, for example one enjoyed loud music and the other did not. The service user told the inspector s/he did not like sharing and would prefer not to in the future. The manager needs to ensure discussions take place with service users about sharing bedrooms, their views are respected and records are kept of this consultation process. The service users living at the home have differing needs. The majority of staff have received training in managing epilepsy. However, training is still needed in managing diabetes and developing communication skills specific to the needs of the service users. The current service users have been living at the home for more than 2 years. Hence, staff involvement in the home’s referral and admission process has been limited. The manager stated arrangements are made for different policies and procedures to be included on the staff meeting agendas and discussion of the assessment and admission procedures will be included in this process to ensure staff are familiar its content. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. Service users are consulted about their care in regular meetings with their key worker. They would benefit further from more details being included in their plans. Service users are provided with opportunities at house meetings to participate in making arrangements for the general day-to-day running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans cover different aspects of service users’ personal, healthcare and social needs. However, more detail is required especially in respect of how service users are supported to make their own decisions and, as applicable, where decisions are made on their behalf. For example the home manages the personal allowance and looks after the cigarettes for some service users. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 12 Although the inspector was informed this had been agreed, there was no record of this arrangement in the care plans or risk assessments. Limited information is provided about how service users are encouraged to lead appropriate independent lifestyles or how they are supported to take controlled risks. The key worker and service user meet each month to discuss individual progress and any concerns or matters of interest that arise. The home’s policies, procedures and the general running of the home are discussed at service users’ meetings. Records are kept of these meetings. Staff spoke positively about the 1:1 meetings and ‘house’ meetings. They stated individual meetings encourages the service user to discuss their feelings, allows them to express their wishes and enables staff to assist them in preparing for their reviews. Staff stated service users have become more supportive to each other in ‘house’ meetings and exchange views on menus and group activities. Service users who expressed a view said they looked forward to individual and ‘house’ meetings and were well looked after by all the staff. A full review of the care plan takes place with the service user, manager, relative/representative and relevant professionals on an annual basis. The manager is aware reviews need to take place at least once every six months. The daily records kept by the home do not routinely make reference to the individual’s care plan. More effective recording in this area would benefit the monitoring and review process. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. Service users are supported to follow their preferred routines, access educational and social facilities and maintain contact with family and friends. Activities for service users will be more fully met once the home has completed its review of individual programmes and appropriate arrangements have been put in place. The home provides service users with a choice of meals and flexible mealtimes. However, alternative arrangements need to be made for service users who choose to smoke to ensure the dining room remains a smoke free environment at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 14 Service users attend day centres during most weekdays. This provides them with opportunities to develop their practical and social skills and makes arrangements for individuals to attend suitable college placements. The home has good relationships with the centres and support service users by attending progress meetings arranged by the centres. The home offers a range of activities such as board games and external activities that include cinema and bowling trips and pub lunches. Staff confirmed arrangements are made for service users to enjoy an annual holiday or, if they prefer, short trips throughout the year. Each service user has an activity programme that is currently being reviewed. The manager stated the process involves consulting with service users in ‘house’ meetings and key worker sessions. A member of staff informed the inspector one service user had expressed an interest in gardening and a request was being made for a greenhouse. During the inspection one service user stated they did not like shopping and did not want to go that day. The purpose of the trip was to purchase new clothes and toiletries for her/his holiday. Staff explained this to the service user who agreed s/he needed to purchase some items and decided to go on the shopping trip after all. The Service User Agreement in the Service User Guide (October 2006) provided to the inspector states the weekly fee covers “…Day to day travel/Recreational and day activities…” and an annual holiday. Where applicable, staff escort service users to appointments, social activities and visits to family and friends. The Statement of Purpose (October 2006) states the home has “…a vehicle to assist in facilitating access to communitybased activities…”. The inspector was informed the home does not have sole use of this vehicle, but shares it between other homes within the group. This sometimes inhibits the home from responding to spontaneous requests for trips out. Fortunately most of the current service users have good mobility and the home is situated in West Bromwich town, where shops and some recreational facilities are easily accessed. However, as reported on at previous inspections, and by staff, service users would benefit from the home having its own transport. Visitors are welcome to the home at any reasonable time and invited to join in some of the activities. As previously stated, where required, service users are assisted to visit relatives and friends. Staff are sensitive to needs and wishes of service users about who they wish or do not wish to see. For example one service user prefers receiving visits from a relative on a planned day, as unplanned visits sometimes causes the service user to become anxious or distressed. Staff are aware of each service users preferred routines. One service user enjoys rising early and preparing her/his own breakfast. An initial risk assessment carried out for this activity identified a member of staff needed to Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 15 be present at all times to provide support and supervision. The service user has made significant progress and is able to carry out this activity with reduced supervision. However, service users preferred routines and what support is provided needs to be more clearly recorded on the care plans and progress records. It is pleasing to report the home has provided the service user identified in the last report with a key to her/his bedroom. Staff and service users discuss menus at the ‘house’ meetings. Weekly menus are displayed in the kitchen and include two options. Alternative meals are provided on request. Individual records are kept of the meals taken. The home is in the process of further developing its pictorial portfolio for meals, to assist service users with limited communication skills. Service users who gave an opinion stated they enjoy the meals provided by the home. Mealtimes are flexible to accommodate service users routines. Care staff are responsible for carrying out all catering duties. The records show six staff have attended Basic Food Hygiene training and arrangements are being made for the remaining staff to attend the next available courses. Staff would benefit from additional training for specific dietary needs, such as diabetes. The home has a smoking policy for service users who chose to smoke. During inclement weather service users are able to use the conservatory/dining room when meals are not being serviced. The unsuitability of this arrangement was discussed with the manager, who stated a more acceptable arrangement will be provided. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. In general the home provides personal support in accordance with service users needs and preferences. Arrangements are made for healthcare needs to be met. However, to ensure service users with specific needs are appropriately supported training in this area should be provided to staff. The health and wellbeing of service users is protected through the home’s systems for administering and managing medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who expressed a view stated they are happy with the way their care needs are being met. The inspector observed a good rapport between service users and staff. Service users were addressed by their preferred name and spoken to with respect. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 17 Healthcare plans are available and records show service users are supported to access relevant health care services, such as their general practitioner, consultant, dentist, optician and chiropodist. However, more details need to be provided about how service users are supported to communicate their feelings and wishes effectively. As previously stated, training in developing communication skills specific to the needs of individual service users has not yet been provided to staff. The home makes adequate provision for the safe keeping of service users medication and has met the requirements made at the last inspection. The home has taken action to reduce the temperature in the room where the medication is stored. The records show the temperature remains stable. Staff record dates when creams, drops and ointments are opened. All applications are included on the medication administration records. Appropriate instructions are provided for the administering of all medication and records are suitable maintained. Sample of the signatures and initials are kept available of each staff member responsible for administering medication. The inspector was informed six staff are responsible for the administering of medication, two seniors and four care staff. The records show these staff have completed training in managing medication. The manager is arranging for other staff to receive this training in the near future. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. Service users are consulted on a daily basis and are satisfied with the way the service responds to their comments and concerns. All staff should be trained in adult protection issues to ensure service users safety and well being is fully protected. Systems are in place for managing the service users’ personal allowances. However, to ensure the best interests of the service users are fully protected these arrangements should be detailed in the care plans and discussed at reviews. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received by the home and none have been reported to Commission for Social Care Inspection (CSCI). A copy of the home’s complaints procedure is attached to the Statement of Purpose and information is provided in the Service User Guide. Service users identified a suitable person/s they would approach with any concerns they may have. Staff stated regular meetings with service users enable them to address any concerns or worries at an early stage. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 19 Adult protection policies and procedures are available in the home. However, records show no adult protection training has been provided. No adult protection concerns were identified during this visit. Staff stated service users relate positively to each other. Information about independent advocacy services is available from the home. All current service users have a relative or representative to advocate on their behalf. Where a local authority’s appointee-ship unit manages service users finances, arrangements are made for personal allowances to be forwarded to the home’s company head office. The home has suitable systems in place for managing monies they look after on behalf of the service users. This information should be clearly detailed in care plans and discussed at the individual’s reviews. Issues reported on at the previous inspection in respect of payment for meals out and holidays have been addressed. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. Service users live in a clean and safe environment and have benefited from the redecoration and refurbishment work that has been carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have freedom of access to communal areas such as lounge, dining room and, subject to a satisfactory risk assessment, the kitchen and laundry. Service users are able to access the garden via the dining room. Since the last inspection visit some areas of the home have been redecorated and carpets replaced. A new shower has been fitted on the first floor. The majority of areas reported as requiring attention have also been addressed. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 21 The issue of the damp in the cellar was raised with the manager and the flooring under the fridge/freezer at the top of the cellar stairs remains uneven. Service users individual personalities and interests are reflected in how they have arranged their personal belongings in their bedrooms and some of the rooms have been redecorated. Service users stated they were able to choose their own colour scheme and were pleased with the outcome. An annual programme for redecoration, refurbishment and maintenance needs to be produced to ensure the upkeep of the building is carried out in a timely manner. The home does not employ ancillary staff. Suitable procedures are available for care staff to follow to ensure the home is clean, comfortable and safe. Service users are encouraged to participate in some domestic tasks and, where applicable, are assisted in keeping their rooms clean. One service user commented they like living at the home “…because staff cleans the home and I assist with the cleaning.” Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. The safety and well being of service users are protected through the home’s policies and procedures for the recruitment of staff. A stable and qualified staff team provide service user with care and support. Service users would benefit from staff being supported in their duties with regular supervision and planned training programmes to ensure all care needs are appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A stable staff team continues to provide care to service users, some having been employed at the home for several years. Staff presented as confident in their roles and aware of what is expected of them. The rotas show three staff are on duty for most shifts between 07:00 – 20:00, two between 20:00 – 22:00 and a waking night staff between the hours of 22:00 – 08:00. As previously stated, care staff are responsible for all ancillary duties. The Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 23 manager is advised to regularly review staffing levels against the changing needs of the service users to ensure sufficient staff are provided at all times. Suitable procedures are followed in respect of the recruitment of staff. Records show satisfactory criminal record bureau checks and references are obtained prior to employment. A member of staff who commenced employment in April 2007 has completed a detailed induction pack. The home does not have an established system for the supervision of staff. One supervision and one appraisal session was recorded for a new member of staff and two supervision records were available for longer serving staff. The manager has produced a scheduled for individual supervisions and is aware of the need to provide a minimum of six sessions per year and carry out an annual appraisal. Staff who had received supervision stated the sessions were useful for exploring care issues, discussing policies and procedures and their individual practice. The majority of staff have completed Level 2 National Vocational Qualification. One member of staff confirmed they had completed the basic food hygiene training, attended an update in the safe handling of medication and was currently undertaking training in infection control. The manager needs to ensure a more planned approach is taken to team training and each member of staff has a training and development programme. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. Service users are benefiting from the systems in place to enable them to express their views and the arrangements made to implement changes in care practices. The health and safety of service users are promoted and protected by the home’s policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 25 The manager has the relevant experience required for working in a residential setting with this client group. He is supported by a stable staff team and by regular visits from his manager. The home’s quality assurance system needs to be developed further. The manager has issued surveys to relatives, friends, advocates and stakeholders to ascertain their views about the service and is waiting for their responses. Monthly visits are made by a representative of the company to monitor the home’s performance and a copy of her/his report is provided to the manager. Suitable records are kept of inspections and servicing of appliances and equipment. Accident records are appropriately maintained and, where applicable, the relevant agencies are notified. Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 3 2 2 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 2 12 3 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14 Requirement The procedures for emergency/short notice admissions should be reviewed to ensure the home is able to meet the service user’s needs and to ensure compatibility with other service users. Timescale for action 22/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA2 YA3 YA6 Good Practice Recommendations Staff should be trained in meeting the needs of diabetic service users and effective communication skills. The manager needs to ensure discussions take place with service users about sharing bedrooms, and records of the consultation process kept. Effective recording should be made of service user’s progress to assist the review process Reviews should be held with service user, relative/representative and relevant professionals at least Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 28 4. 5. 6. 7. 8. 9. YA7 YA9 YA13 YA14 YA16 YA17 once every six months to ensure care needs are met and, where applicable, suitable amendments are made. Support for service users to make their own decisions, or reasons why decisions are made on their behalf, should be detailed in the individual’s care plan. Risk assessments should include details of how service users are supported to lead an independent lifestyle and take controlled risks. Consideration should be given to improving service users access to impromptu activities by providing the home with its own transport. Arrangements must be made to ensure service users personal development and recreational preferences are met. Service users preferred routines and support provided should be clearly recorded on their care plans. Staff should be provided with training that meets service users specific dietary needs. The home must arrange for the dining room to remain cigarette smoke-free at all times. All staff should receive training in adult protection issues. Arrangements for managing service users finances must be detailed in the individual’s care plan and discussed at her/his reviews An annual programme should be produced to ensure the redecoration, refurbishment and maintenance for the premises are carried out in timely manner. Staff should be supported in meeting the needs of service users through suitably planned training and development programmes. Staff should be supported in their roles by receiving a minimum of six supervision sessions a year and an annual appraisal. The views of service users, relatives and other stakeholders should be included in a comprehensive quality assurance system to enable the home to produce improvement strategies. 10. YA23 11. 12. 13. 14. YA24 YA35 YA36 YA39 Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westgate DS0000004827.V337870.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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