Inspection on 05/03/08 for Westholme

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westholme 21/03/07

Westholme 17/05/06

Westholme 25/01/06

Westholme 24/08/05

Westholme 20/12/04

Westholme 15/05/04

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

CARE HOMES FOR OLDER PEOPLE Westholme 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE Lead Inspector Lesley Plant Unannounced Inspection 5th March 2008 09:30 X10015.doc Version 1.40 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 Westholme DS0000009752.V339431.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 Older People. 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. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westholme Address 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE 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) 01253 727114 Mrs Vivien Perry vacant post Care Home 35 Category(ies) of Dementia (35) registration, with number of places Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 35 Date of last inspection 21st March 2007 Brief Description of the Service: Westholme is registered to accommodate 35 people with dementia. The property is large; with accommodation spread over three floors. A stair lift provides access to the upper floors. During the past two years Westholme has been undergoing an extension and refurbishment programme with the aim of improving the facilities. The home now provides a good variety of communal rooms, including a conservatory. A lift is currently being installed. There are attractive gardens to the front of the home and a small enclosed decked patio at the rear. These areas are accessible to those living at the home. The home is located near to the centre of St Annes, close to local services and amenities. The registered provider has owned the home for over 25 years. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place during the course of one day and looked at all the key National Minimum Standards plus supervision arrangements for staff. At the time of this inspection there were 17 people resident at the home. Two inspectors carried out the inspection. Discussions took place with, the deputy manager (acting manager) and a number of staff. Records and documentation were viewed and a tour of the building was carried out. One inspector spent the morning period observing the support being provided to a small group of people living at the home. CSCI questionnaires inviting feedback about Westholme were received from six relatives and five members of staff. Three people living at the home were supported to complete questionnaires. Information was also gained from the Annual Quality Assurance Assessment completed by the deputy manager of the home. Since the last key inspection in March 2007, two ‘random’ inspections have taken place. (Random inspections are conducted to look into particular areas of service provision and do not look at all the key national minimum standards.) Reports relating to these visits in October and November 2007 are held at the CSCI office and will be made available to enquirers on request. Following the last key inspection the registered provider produced an improvement plan, which was supplied to the CSCI. What the service does well: The staff team has remained stable for some time, meaning that staff have got to know the people living at the home very well. The relationships between staff and those living at the home appeared warm and affectionate. Staff keep good records regarding health and daily activities, with the monthly review report giving a good picture of how each person is. These clear recording systems make it easy to find information and monitor any changes. The arrangements regarding medication appear to be well organised, with good practice in place. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 6 The range of communal living space gives different options regarding where people living at the home spend their time, allows for different activities to take place and provides quieter areas for visitors. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. The assessment process helps to ensure that people are only admitted to Westholme if their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records were viewed, in relation to two people who had recently been admitted to the home. Assessments had been carried out prior to admission, with only senior staff having this responsibility. The information gathered addresses social, leisure and physical health needs. Separate assessments had taken place regarding the risk of falling, moving and handling, mobility, personal care and behaviour. Personal profiles were in place on the records viewed. These give staff a useful overview of the individual’s life history and for one person, a close relative had written the life history. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 9 Information from other agencies was also available on files. For some people this includes a pre discharge assessment from hospital. Prospective residents and their relatives are invited to visit the home prior to admission in order to view the facilities and meet the residents and staff. Intermediate care is not provided at Westholme. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Care plans are in place and are regularly reviewed, meaning that changes can be responded to. Behaviour plans are basic. Improvements in this area would help staff to develop individualised approaches. Health care needs are being met and medication arrangements are well organised. Privacy and dignity are promoted during the day-to-day work of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place and address needs and preferences in such areas as physical and mental abilities, health and hygiene. The care co-ordinator carries out monthly reviews of care plans. The records viewed showed that these regular reviews are taking place, with a written overview reflecting upon how the person has been during the past month. Changes are made to the plan of Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 11 care as necessary. For one person a change had been made following a period of ill health and a stay in hospital. Comments from relatives who completed feedback questionnaires for the inspection included; “ It is a happy and friendly home and I am very pleased with the day to day care of my relative.” Care plans continue to improve, however there is still some work to do regarding the delivery of care being more individualised and person centred. Behaviour plans are in place but these need to be individualised, for example where an individual may be resistant to receiving personal care or become upset or aggressive. The behaviour plans generally advise that the individual is left for a while and that another member of staff then approaches them. This is good general advice but behaviour plans should include guidance specific to the individual. Strengthening of the key worker role may help in this area, as would continual training and guidance for staff regarding working with people with dementia. The manager too needs to build up knowledge and expertise in this area. Staff maintain good records of health care and these include records of GP, district nurse, chiropody, and physiotherapy visits. Some people also have support from a community psychiatric nurse. Records of weight are also kept. Staff have to keep records of blood sugar levels for one person who has diabetes. During the inspection this individual became unwell, with raised blood sugar levels. Staff responded according to the agreed protocol and advice given by nursing staff. The staff on duty were all aware of how to respond to such circumstances, however it was advised that there is written guidance available for staff. Staff keep good daily records, which include issues regarding health care and an overview of how each person has been, including eating and sleeping. A physiotherapist visits the home each week to conduct a group exercise session and pressure relief aids are available. Information is displayed in the small staff office regarding the safe use of bedrails and particular health conditions such as diabetes. Patient information leaflets are also available regarding any prescribed medication, possible side affects etc. Risk assessments are carried out regarding the use of bed rails and these are reviewed alongside the care plan. The risk management plan includes the regular checking of this equipment and the need to use protective padding on the bedrails. The inspector observed that this was in place. Medication is safely stored and only administered by senior staff who have undertaken training in this area. The medication administration records viewed Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 12 were being correctly maintained. A separate record is kept of any non prescribed (homely remedies) medication, which has been given. Medication records include a photograph of the individual concerned and there is specific guidance regarding any medication, which is prescribed to be administered ‘when required’. The majority of medication is provided in blister packs. It was noted that other medication, such as eye drops, is dated when it is opened, which is agreed good practice. The pharmacist is available for advice and there are records of his visits to the home. Privacy and dignity are addressed with all new staff during the induction period. Screening is provided in the double bedrooms. During the inspection staff were observed responding gently and sensitively to individuals. A staff member offered reassurance and explained what she would do, when a resident complained of feeling unwell; and staff approached residents in a respectful manner, addressing them by name. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Recreational interests are supported on an individual and group basis. Visitors are made welcome and homely meals are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The separate living rooms allow for different activities to take place. In one room people like to watch television, in another DVD films are shown and in the third, the radio is preferred. Staff also initiate different activities in the home and a record is kept on each file of what the person has taken part in. Activities include hand massage, manicure, knitting, karaoke, group singsongs, and colouring. On the day of this inspection staff were encouraging individuals to read or look at magazines and were encouraging discussions about different articles. Some activities also take place outside the home and a group had recently been to a hotel for a specially arranged sing along afternoon. An entertainer is booked to visit the home every month. Hairdressing and chiropody are also regular events. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 14 Three people living at Westholme were supported to complete feedback questionnaires. Two responded that they usually enjoy the activities and one responded always. One inspector spent the morning observing a small group of people and the support provided by staff. The relationships appeared warm and affectionate. Some good practice was observed, such as a conversation about a magazine a resident was looking at. A staff member encouraged the resident to explain her opinions and to discuss pictures and articles she was interested in, as they looked through the magazine together. The staff member later brought the resident a book of recipes as she had shown particular interest in the recipes in the magazine. It is this individual one to one time which should be encouraged and become a regular part of daily life at the home. The strengthening of the key worker role may help in this area. Visitors are made welcome and several comments were received from relatives regarding the conservatory being a pleasant place to sit and chat. The people living at Westholme all have a diagnosis of dementia resulting in various degrees of cognitive impairment. Relatives usually take responsibility for financial affairs. Details of advocacy services are available. People are able to bring personal possessions into the home and so make their bedrooms homely. There is now a new kitchen, sited at the rear of the home. This new facility appears to be working well. A three weekly rotating menu is in place and this was viewed. The main meal is served at lunchtime and although the menu does not show a set choice, the cook is aware of people’s preferences and alternatives are available, as seen on the day of this inspection. The cook is also made aware of any specific dietary needs and is able to cater for these, such as meeting the needs of people with diabetes. Three people living at Westholme were supported to complete feedback questionnaires. One responded that they usually like the meals and two responded always. Consideration should be given to introducing choices into the menus and not just providing an alternative for people who don’t like the main meal. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Arrangements for handling complaints are in place. Staff training regarding vulnerability and protection would strengthen the safeguarding procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place, which gives a clear timeframe within which concerns would be responded to. No complaints have been received by the home or by CSCI since the last inspection. The staff spoken to were clear about the procedure to follow, should any concern be raised. The six relatives who completed feedback questionnaires all confirmed that they are aware of how to make a complaint, should this be necessary. The home’s policy regarding abuse and protection has been reviewed and updated and now includes clear reference to locally agreed procedures. The registered provider is aware of action to be taken, should a safeguarding issue be raised. Not all staff have undertaken training regarding vulnerability and protection. This should be arranged and also included in the induction training for all new staff. Information regarding whistle blowing is displayed in the medication room for staff to read. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 16 Care plans now include guidance for staff regarding how to respond to physical or verbal aggression. Although useful these should be developed and individualised, promoting a more person centred approach. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. Although greatly improved, the continual building work means that access within the home is restricted. Minor repairs are also required in order to provide a good environment for those living at Westholme. The home is clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Good progress has now been made with the building and refurbishment programme for the home. The new kitchen is working well and the new dining room and conservatory provide pleasant communal space for those living at Westholme. A number of bedrooms and one of the lounges have also been refurbished. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 18 A number of relatives who completed feedback questionnaires for the inspection commented on the new conservatory and how it provided a quiet and pleasant place to sit when visiting. A lift is being installed and whilst this work is ongoing there are certain necessary access restrictions in place. The deputy manager informed the inspector that work on the lift is now complete but that there was still some work to be done in the surrounding areas/landing before it could be used. It is anticipated that this work will soon be concluded. There are then plans to connect the two sides of the building with a first floor link corridor. Once complete this will improve access for all. Building control and the fire and rescue service have been visiting the home to advise and ensure compliance with associated regulations. A tour of the building took place. Some areas still require attention, such as a bedroom with peeling wallpaper and there were four radiator covers either loose or not attached to the wall. This appears to have come about due to workmen having had access to the radiators. At present there is no maintenance worker employed at the home. The member of staff who had certain maintenance duties has now left employment. The deputy manager explained that the workmen assigned to carry out the building work at the home would also now be available for minor repairs. It is important that general maintenance and minor repairs are dealt with. A housekeeper and a laundry worker are employed at the home. Night staff also carry out certain domestic and laundry duties. The home appeared generally clean. Protective gloves and aprons are available for staff and infection control measures are in place. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The home is staffed appropriately and NVQ training is promoted, providing opportunity for staff to develop further skills in their work. Recruitment procedures promote the protection of people living at the home. A more thorough induction process and training in key areas would increase staff competence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this unannounced inspection there were 17 people resident at the home, with three care staff on duty plus the deputy manager. In addition there was also a cook and a housekeeper on duty. Rotas showed that there would be three staff available during the evening, with two night staff then commencing duty. The rotas viewed confirmed staffing levels of three or four care staff on duty each day, plus the manager and on most days two housekeeping/laundry staff plus the cook, were also working. These staffing levels appear to adequately address the needs of the current residents. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 20 Feedback questionnaires completed by relatives contained a number of positive comments regarding staff at the home, including; “The staff appear to genuinely care for the residents.” The staff team consists of the deputy manager and 14 care staff. Three staff have achieved NVQ (National Vocational Qualification) level 2 and will be commencing the level 3 award. Seven staff are currently working towards gaining the level 2 or level 3 awards. The housekeeper is also undertaking NVQ training relevant to her role. The deputy manager is a qualified NVQ assessor and acts as assessor for some of the staff engaged in this training. Qualification training should continue in order to achieve the nationally agreed targets of having 50 of care staff qualified at NVQ level 2 or above. The recruitment records for a member of staff who commenced work in September 2007 were examined. Documentation includes an application from, health questionnaire, record of interview, contract, job description, two references, Criminal Records Bureau disclosure and Protection of Vulnerable Adults check. Since the last key inspection, all care staff apart from the deputy manager have undertaken training regarding dementia and challenging behaviour. This was a half-day course and certificates of attendance were seen on staff files. Some staff have also taken up the opportunity to undertake literacy courses. A training matrix is in place and shows that the majority of staff have undertaken the basic core-training programme, which includes heath and safety topics. Dates when refresher training is due are clearly marked on the matrix. There are some gaps in the basic training programme, with one staff member spoken to, not yet having completed moving and handling training. Although some training regarding dementia has been provided, expertise and knowledge in this area needs to further developed, by more advanced training or in house supervision and guidance from skilled and experienced senior staff. The deputy manager needs to develop expertise in this area and ensure that staff are guided appropriately. Induction training was discussed with the deputy manager. New staff work alongside more experienced staff and the home has developed an induction checklist. The induction checklist for the staff member who had commenced in September 2007 was viewed. This is useful and covers certain basic topics. A senior member of staff had signed off each element. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 21 The induction programme for new staff needs to be mapped against the ‘Skills for Care’ induction standards and should cover health and safety topics, dementia and training regarding vulnerability and protection, which has not yet been made available to staff. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. Quality monitoring systems are not always being effectively applied, meaning that areas for improvement may not be identified or actioned. Regular staff supervisions would help to ensure consistency. Appropriate training for all staff will help to promote the health and safety of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The deputy has been acting manager of the home since the previous manager left in October 2007. Since this time the deputy has worked hard to establish effective day-to-day procedures within the home and has recently applied for Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 23 registration with the CSCI. Qualifications gained during the past 18 months include NVQ level 4 in Care, the NVQ Assessors award and the Registered Managers Award. The deputy has over 20 years experiences in the care sector, working with older people and people with disabilities. A care co-ordinator and senior care staff also carry out certain management duties at the home. The deputy manager regularly meets with the registered provider and meetings with senior staff also take place. As well as ensuring that all staff build up knowledge and skills in working with people with dementia, it is vital that the deputy also develops expertise in this area. Quality monitoring and quality assurance systems are being developed. The home sent feedback questionnaires to all relatives last autumn. The responses were viewed and give mainly positive feedback about the service provided at Westholme. A number of people indicated that they felt communication and being kept informed of their relatives’ wellbeing could be improved. The deputy manager felt that improvements had been made, although any specific action taken as a result of this feedback was difficult to pinpoint. It is important that questionnaires are regularly distributed and that responses are collated, with clear action showing how any issues raised are to be addressed. Westholme has achieved the Investors In People Award, which has recently been reviewed and an action plan provided. This includes addressing shortfalls highlighted in previous CSCI reports, such as improving formal supervision and appraisals for staff. Staff meetings are now taking place, with one held in January 08 and another planned. Following the last key inspection the registered provider produced an improvement plan, which was supplied to the CSCI. Monitoring of improvements must continue. In line with regulation, the registered provider had been forwarding a monthly report to the CSCI. However, these are not being consistently received and this must be addressed. The deputy manager of the home completed the annual quality assurance assessment. This contained basic information, whereas it could have been used as an opportunity to reflect upon recent improvements and plan for further development and improvements in service provision. It is important that the registered provider is party to any future annual quality assurance assessments and takes responsibility for the quality of information provided. The people living at Westholme all have some degree of cognitive impairment and are unable to manage their financial affairs. A relative or representative, such as a solicitor takes this responsibility. Records are kept of any expenditure, such as hairdressing or trips out and the relative or representative is then periodically billed for this amount. The records viewed appeared to be well maintained, with clear detail of any expenditure by each Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 24 person. The deputy manager explained that this system works well and that the representative would be asked prior to any unusually large planned expenditure, such as a significant amount of new clothing. A format for staff appraisal has been developed and includes a self-appraisal by the employee as well as an appraisal by the supervisor. The deputy manager explained that this system is not yet fully established. The staff spoken to confirmed that they felt supported in their role and could ask for advice at any time. Providing formal recorded supervision to each member of care staff at least six times annually would strengthen this informal supervision and support. Health and safety checks take place. Records viewed included fridge temperatures; the temperatures of meat on delivery, water temperatures, fire equipment and fire door checks, stair lift maintenance and legionella testing. The fire alarm is regularly tested and records are kept of routine maintenance jobs. Although water temperatures are being monitored, the records showed that the water temperature in one room had been recorded as high and out of the safe range. This was on more than one occasion, but no remedial action had taken place. It is important that the results of any such monitoring are swiftly responded to. Water must be maintained at safe temperatures. The local environment agency had recently visited the home to carry out food hygiene checks. Some recommendations had been made and the deputy manager confirmed that these had been put into place. One recommendation regarding installing a dishwasher had not yet been actioned. This is important for hygiene reasons and also for practical purposes and will be particularly important for when the number of residents increases. The gas installation had been checked in January 08, however no safety certificate was available. The inspector was informed that the contractor had not yet supplied this and that this would be addressed. Training records show that the majority of staff have undertaken health and safety related training, such as food hygiene and moving and handling. There are a small number of staff who have not completed these basic mandatory courses and this should be addressed. One staff member spoken to had not completed fire safety or moving and handling training. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 26 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. 2. 3. Standard OP19 OP31 OP33 Regulation 13 and 23 8 26 Requirement The registered provider must ensure that the home is well maintained. The registered provider must have a manager in post who is registered with the CSCI. The registered provider must carry out monthly monitoring visits and provide the CSCI with a report. Safe water temperatures must be maintained. Timescale for action 31/03/08 30/05/08 31/03/08 4. OP38 13 14/03/08 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 OP7 OP18 Good Practice Recommendations Care plans should be developed in a person centred way and include individualised guidance regarding challenging behaviour. All staff should undergo training regarding vulnerability, abuse and protection. Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 27 3. 4. 5. OP28 OP30 OP31 Progress with NVQ training should continue; in order to achieve 50 qualified staff. Induction and core training should meet the ‘Skills for Care’ standards and include training regarding dementia. The deputy manager should undergo training regarding dementia and develop knowledge and expertise in this area. All care staff should receive supervision at least six times a year. Quality assurance systems should continue to be developed. All staff should undertake training in health and safety topics. 6. 7. 8. OP36 OP33 OP38 Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Westholme DS0000009752.V339431.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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