Inspection on 10/04/07 for Westhaven

This inspection was carried out on 10th April 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westhaven 19/09/05

Westhaven 03/05/05

Westhaven 08/12/04

Westhaven 07/08/04

Westhaven 26/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Westhaven Westhaven 68 Blackborough Road Reigate Surrey RH2 7BX Lead Inspector Susan McBriarty Unannounced Inspection 10th April 2007 09:00 Westhaven DS0000013822.V333229.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 Westhaven DS0000013822.V333229.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. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhaven Address Westhaven 68 Blackborough Road Reigate Surrey RH2 7BX 01737 221503 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) westhaven@millsted.co.uk Millsted Care Limited Amanda Vivienne Finch Care Home 6 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 41-65 YEARS & THREE OVER 65 YEARS 19th September 2005 Date of last inspection Brief Description of the Service: Westhaven care home is owned and managed by Millstead Care Limited and is registered for six (6) people with a learning disability. The home has a fully equipped kitchen, dining room, living room and six single bedrooms, one of which is ground floor and en-suite. A good size garden is available for use. The property is located in a pleasant residential area in close proximity to two local towns, Reigate and Redhill. The home has its own transport, which is accessible for current service users. Fees for 2006/2007 range from £1,000 to £1,300 per week. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven hours (7) hours, commencing at 9.00am and ending at 4.00pm. Ms Susan McBriarty regulation inspector carried out the visit. The registered manager of the service was present during the afternoon of the inspection and the person in charge assisted in the morning. The inspection took into account the pre-inspection questionnaire information and records held at the home including service user files, staff personnel files, supervision, training, medication administration and daily records. The inspector made observations of interactions between staff and service users during the visit. The commission had received fourteen (14) comment cards from service users and other sources (such as relatives) by the time of the visit. The service users at the home have learning disabilities and the commission would need support to assist service users to talk in a detailed way about the home. What the service does well: What has improved since the last inspection? The majority of requirements made during the inspection of the 19th September had been met and the one recommendation made had received action. No significant changes in the service were brought to the attention of the commission during the site visit. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 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 Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual aspirations and needs of service users are generally assessed prior to service users moving into the home. EVIDENCE: A number of service user files were sampled including that of the most recent admission. The commission were informed by the person in charge that the original assessment information was held at the head office. Assessments from other professionals and a copy of a care plan from a previous home were on the file of the new admission. The commission were informed that the assessment for the named service user completed by the home was also held at the head office. The person in charge said that information documented and recorded by the home was archived each year and that this was why the information was not on the files. It is recommended that the home place the assessments completed by the home in the service users file as this will confirm that service users needs and aspirations are met by the home. Standard 4 was not assessed however one service user told the commission that they had visited the home before moving in and saw the vacant bedroom and met the others living in the home. Feedback in the comment cards from service users confirmed this. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some improvement was needed to confirm that service users assessed and changing needs including the option of taking risks were reflected in their individual plans. Service users are able to make decisions about their lives with assistance as necessary. EVIDENCE: A number of service user files were sampled. The home uses the care plans provided by the local authority when carrying out the admission and reviews of service users placements. The person in charge told the commission that some of the updated care plans and minutes from reviews carried out in 2006 with the local authority had not been received despite requests being made. Reviews of the care plans are carried out with the service users each month; records and documents seen confirmed this all those sampled had been signed by service users. A requirement is made that the home design and use their own care plans, this will ensure that the assessed and changing needs and personal goals of service users are recorded in their individual plan taking into Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 10 account the possible problems in gaining up to date information from the placing local authorities. Feedback and discussion with one of the service users confirmed that they felt able to make their own decisions and that care staff listen to and act on what they say. The person in charge, manager, a member of staff, local authority documents as well as observations made throughout the visit confirmed that service users have the right to make decisions and that these are limited only through the assessment process. One member of staff said that they had learnt a lot from starting work at the home including that the home makes it clear that service users have rights and can make their own decisions whenever possible. The service user files sampled recorded and documented what risks had been identified and what action was needed to reduce those risks. The person in charge said that all the risk assessments were reviewed annually the documents seen confirmed this. One risk assessment was missing although other evidence was available in the file that documented the aggressive behaviour that might be seen. Although the commission were informed that the risks had lessened over time a recommendation is made to ensure that a review takes place and any risks identified have lead to a documented risk assessment being completed. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 11 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): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in age, peer and culturally appropriate activities and their rights and responsibilities are recognised in their daily lives. A healthy diet is offered and mealtimes are enjoyed. EVIDENCE: The home documented the activities taking place including access to day centres. The pre-inspection questionnaire and daily records seen confirmed what activities were available and which service users had actually attended. The activities take into account the age and preferences of the service users. Discussion with the service users and observations made during the visit confirmed other activities taking place on an ad hoc basis. For example one service user spoke of going to the local park for a picnic the day before another said they had decided to go to church the following week. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 12 Changes had taken place regarding the recording and documenting of service users finances. The person in charge and later the manager confirmed that payments received by service users are set out and discussed with service users. This matter was also confirmed in writing following the inspection on the 19th September 2005. In addition the service users are clearly informed by members of staff that the benefits received are theirs. The requirement made during the last inspection had been met. The service user guide stated that an annual holiday can be arranged and that the home can subsidise the cost where necessary. The manager said that the home pays the full cost of all other trips out. The management of the home were advised to review the information provided in the service user guide taking into account the statement in standard 14 of The National Minimum Standards for Young Adults that all long-term placements have the option of a holiday as part of the basic contract price. Family links and friendships are supported by the home wherever possible. For example on the day of the visit one service user was being visited by someone they had not seen for a significant number of years. Another friend of the service user and the staff at the home had supported the visit. Members of staff were observed knocking on service users bedroom doors before entering, addressing service users by name with respect and dignity. Those service users who wish may lock their bedroom doors and keep the key. Throughout the visit observations were made that staff consistently placed interaction with service users as more important than with each other. Occasional entries in the daily notes said such things as ‘being disagreeable’, the person in charge was aware of these and said that members of staff were reminded to make sure they wrote what happened and not their view of a situation. The commission were told that this would again be brought to the attention of staff We took lunch with the service users and observations noted that each was asked what they preferred to have in their sandwich and to drink. The lunch period was relaxed and service users talked to members of staff and the commission about their day. The home no longer attends the local shops to purchase food for the week but uses on line shopping options leaving care staff and service users to do other things, such as going out. The service users were said by the person in charge to continue to make their choices about what they would prefer to eat during the week. During lunch one service user had noted that the order for a particular item had not arrived and wanted to go the shops that day to buy the missing item confirming involvement in the process. The menu provided by the home with the pre-inspection questionnaire and discussions during lunch on the day of the visit evidenced a varied diet with Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 13 knowledge of the personal needs and preferences of individual service users including seasoning choices and low fat options to support healthy eating. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and need and their physical and emotional health needs are met. Some improvement was needed to confirm that service users are protected by the home’s policy and procedure for the administration of medication. EVIDENCE: The service user files sampled, correspondence from health specialists, records and documents seen confirmed that service users receive care and support in the way they prefer and their health and emotional needs are met. For example a letter from a health specialist commended the home for the action taken to deal with the particular health needs of a service user. Annual health checks were completed by a doctor at the local health centre, the person in charge said that the doctor was also a specialist and was able to work with service users whose communication skills at times required support from others. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 15 All the service users at the home were white British and no cultural and religious needs relating to personal and health care had been assessed as requiring specific assistance or provision. The care staff team had received training to carry out the administration of medication, certificates of training, information provided in the pre-inspection questionnaire and discussion with the person in charge and manager confirmed this. The commission made observations during the lunchtime administration of medication and appropriate procedures were followed for safe administration. A procedure was in place that made clear what members of staff were expected to do when administering medication. No errors in recording administration were found and where as necessary medication was given information was provided in writing on the back of the medication administration information sheet. The procedure set out what to do in the event of an error but did not include contact with an appropriate health specialist to confirm what action might need to be taken if incorrect medication was given. The procedure required members of staff to inform the person in charge or manager of any error. As necessary medication was in use and the medication administration information set out when such medication was to be given. The home did not keep records other than confirmation of administration of how much as necessary medication remained. One entry completed by the pharmacist stated a medication, no longer in use, was to be administered ‘as directed’. Feedback from a General Practitioner and two health and social care professionals said that the home dealt appropriately with medication. A recommendation was made that the home review the matters raised by the commission regarding the administration of medication to confirm that service users are protected by the home’s policy and procedure for the administration of medication. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some work was needed to confirm that service users views were listened to and acted upon and to confirm they are protected from abuse, neglect and self-harm. EVIDENCE: Feedback from six service users said that they knew how to make a complaint and who to talk to if they were unhappy. Three relatives were aware of the complaint procedure and one was not, none of the relatives had made a complaint about the home. Feedback from health and social care professionals including the doctor said that they had not received or made a complaint about the home, one said this is ‘an excellent home’. The pre-inspection questionnaire, discussion with the person in charge and the manager confirmed that no complaints had been received by the home. The commission had received no complaints since the last inspection. The home had a copy of the local authority multi-agency guidelines for safeguarding adults and a short clear procedure for members of staff to follow should an allegation of abuse be made. No referrals had been made by the home or received by the commission regarding concerns or allegations of abuse since the last inspection. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 17 The procedure drawn up by the home to safeguard service users might benefit from additional information informing members of staff what to do and what not to do in the event of an allegation, for example what they might say and how to record the information. The complaint procedure had an easy read version with pictures for service users. The person in charge said that each service user had been given a copy to keep in their bedroom. The pictures were very clear however they identified abuse such as hitting and shouting. In discussion with the manager it was agreed that the pictures would be best used to support their safeguarding policy and procedure and for others to be used for the complaints procedure. This would reduce the risk of any confusion by service users as to what might be a complaint. A whistle blowing policy was in place and identified the right of members of staff to inform the manager and others of any concerns they might have about other staff working at the home. The policy does not make reference to the safeguarding procedure although it includes allegations of abuse as a reason for whistle blowing. A requirement is made for the home to review the policies and procedures to ensure that each policy is clear and that any confusing or missing information is identified and changed or added as necessary. This will confirm that service users views are listened to and acted upon and they are protected from abuse. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, comfortable and well maintained home. EVIDENCE: A tour of the home took place and all the communal areas and bedrooms were seen. Work had taken place in the home and garden since the last inspection. For example new fencing was in place externally. Internally a new kitchen was nearing completion and a new carpet had been laid in the living room. Plans were in place for other areas of the home such as replacing the laminate flooring in the dining area. All the bedrooms had been provided with locks and service users could choose to keep their bedroom door locked or not. The service users had personalised their bedrooms, items purchased reflected preferred interests and or colours. The home was clean and hygienic throughout. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35 and 36 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was needed to ensure that service users receive support from appropriately trained and qualified members of staff. The service users were generally supported and protected by the recruitment policy and procedure of the home and benefit from well supervised members of staff. EVIDENCE: The person in charge, manager and pre-inspection questionnaire confirmed that four of the ten care staff had completed a National Vocational Qualification of level 2 or above. The home did not have a central record showing what training had been provided to who or how often refresher training was required by the home. The manager said that they were sure one was held at their head office. The staff files sampled evidenced training taking place and copies of the certificates of completion were held in the same files. For example infection control, breakaway training and life support. Evidence that health and safety training and social nail care had been completed was seen. The manager told the Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 20 commission that they had attended safeguarding adults training and confirmed that the other members of staff had not. A requirement made during the inspection of the 19th September 2005, that training be reviewed to ensure appropriate training took place including health and safety and safeguarding adults had not been fully met. The manager said that a training co-ordinator had been employed to carry out the review and set out the training needs of members of staff and to coordinate all the required training including safeguarding. This had not been successful. The commission were contacted following this visit and were informed by the manager that safeguarding adults training had been arranged for the 24th April 2007. The home had introduced a revised induction programme for new members of staff. To date only one person had begun work after the induction programme started and the training was still on going. A further requirement is made to ensure that a full review of training needs take place including qualifying and induction training and that this is documented, recorded and kept up to date. The training provision must include safeguarding adults and mental health. The home provides for service users who have a learning disability, some also have diagnosed mental health needs. This will ensure that appropriately trained and qualified members of staff meet service users needs. A requirement was made during the inspection of the 19th September 2005 to ensure that all the information necessary to confirm safe recruitment practices were in place. A number of staff files were sampled and the requirement had been met. For example the application forms had been updated to include a full employment history with reasons given for any gaps, references were in place as were documents confirming the identity of members of staff. One file seen did not confirm the reason for a possible gap in employment of education and the manager said they would discuss the matter with the member of staff following the commission’s visit and identify the gap and document the outcome. Although references were in place for all those sampled not all were from the same people identified in the application forms as the nominated referee. The manager said that they did this if a reference was not forthcoming they would ask for the contact name and address of another. The management were Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 21 advised to document when this occurred to show what action had been taken and why. Criminal record bureau (CRB) checks had been completed and the original documents held on the staff personnel files. A recommendation is made that the home review the guidelines provided by the Criminal Record Bureau with particular regard to recording, documenting and storage. Action regarding the recruitment matters raised will confirm that service users are supported and protected by the recruitment policy and practice of the home. The home has a policy in place confirming the code of conduct expected from members of staff, the code supports the code of conduct provided by the General Social Care Council (GSCC) as required in the inspection of the 19th September 2005. The policy had been signed and dated by members of staff as having been read and understood. The staff files sampled, discussion with the person in charge and a member of staff confirmed that documented, recorded supervision takes place on a regular basis. The recommendation made during the inspection of the 19th September 2005 had received action. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 22 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): Standards 37,39 and 42 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users generally benefit from a well run home although some improvement was needed to fully confirm that their health, safety and well being was supported and protected by the home’s policies, procedures and training provision. EVIDENCE: The manager said that they had completed the registered managers award during 2006 and that this added to their National Vocational Level 3 and Assessors award. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 23 The certificate of registration and insurance for the home were up to date and placed where they could be seen. Quality assurance monitoring and development were in place. The process for quality monitoring included team meetings, staff handovers at the change of shift and monthly meetings. The development part of the process included salaries, training and refurbishment of the home. A quality assurance monitoring system was not in place regarding service users and their relatives. A process was not in place to ensure that they had the opportunity to tell the home what they though of the service in a way that was documented and provided written outcomes. Service users and their relatives could not be fully confident that their views underpinned all self-monitoring, review and development of the home. A requirement is made for the home to develop and implement a quality assurance process that includes service users and their relatives, where possible. A number of policies and procedures were seen including equal opportunities, missing persons, infection control and health and safety. All those viewed by the commission had been signed by members of staff as having been read and understood. The pre-inspection questionnaire, tour of the home, the policies and procedures in place and training certificates seen confirmed that the home generally promoted the health, safety and welfare of service users taking into account the matters raised regarding training. Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Timescale for action 29/06/07 2. YA22 3. YA32 The home must devise and implement care plans for individual service users. This will ensure that service users know their assessed and changing needs are reflected in their personal plan. 22 The complaint, safeguarding 13(6) adults and whistle blowing policies and procedures must be reviewed to make sure they are distinct and clear and service users and their relatives are fully confident that their views are listened to and they are protected from abuse. 18(1)(a-c) A review of training including qualifying training must take place to ensure appropriate training takes place including safeguarding adults and mental health. This will ensure that appropriately qualified and trained staff meets service users individual and joint needs. Timescale from the inspection of the 19th September 2005 not met. 29/06/07 29/06/07 Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 26 4. YA39 24 The home must develop and implement a quality assurance process to ensure that the views of service users and their relatives underpin all self monitoring, review and development of the home. 13/07/07 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. Refer to Standard YA2 YA9 Good Practice Recommendations It is recommended that the documented assessments carried out by the home are kept on file at the home to confirm that service users aspirations and needs are met. It is recommended that a review take place to ensure that all areas of risk identified are recorded and documented. This will confirm that service users are able to take risks as part of an independent lifestyle. It is recommended that a review of the policy and procedure for the administration take place to confirm that service users are protected by the home’s policy for the administration of medication. It is recommended that the home review the Criminal Record Bureau guidelines with particular reference to recording and storage. 3. YA20 4. YA34 Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Westhaven DS0000013822.V333229.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!