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Inspection on 20/06/05 for Westhorpe Hall Residential Home

Also see our care home review for Westhorpe Hall Residential Home for more information

This inspection was carried out on 20th June 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home had worked very well in conjunction with other local health services to achieve progress for one resident that was such that they are now on a waiting list for sheltered accommodation. Residents tracked were found to have been encouraged to use their skills and abilities in the life of the home, and expressed considerable satisfaction with this. Residents rate the food at the home highly.

What has improved since the last inspection?

Good progress had been made on a large number of requirements made at the previous inspection. Only one of twenty-six requirements made had not been met, one other has yet to be evidenced. The home had started to act on the recommendations of an occupational therapist, that they had commissioned to advise on the building. A number of improvements had been made to the environment, including the reinstatement of an assisted bathroom. A maintenance schedule was in place. Staff records, including criminal records Bureau checks were all found to be in order. More staff had been recruited to undertake NVQ2.

CARE HOMES FOR OLDER PEOPLE Westhorpe Hall Residential Home Westhorpe Stowmarket Suffolk IP14 4SS Lead Inspector Mary Jeffries Announced Inspection 20th June 2005 10:30 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 Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westhorpe Hall Residential Home Address Westhorpe Stowmarket Suffolk IP14 4SS 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) 01449 781691 01449 781691 Mr K Hunt Ms Virginia R Hunt Ms Virginia R Hunt Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2005 Brief Description of the Service: Westhorpe Hall is a listed country manor house set in its own grounds and in the village of Westhorpe. It has much character, and has been converted to provide long-term residential care for up to 21 older people. The house is approached by a private drive that crosses an ancient moat. There is car parking and gardens that are accessible to the residents. The main house offers accommodation on ground and first floor, with a modern single storey extension to one side. The ground floor comprises two sitting rooms, dining room, kitchen, office, bathroom, WC’s, and several bedrooms in the newer wing. A wood-burning stove had recently been installed in the main lounge, replacing the open fire. The first floor is served by two staircases, both fitted with stair lifts, to two separate wings. The remaining bedrooms, two bathrooms and WC are on this level. In total there are 15 single bedrooms and 3 doubles; one of the doubles is being used as a single room. Four of the single rooms are less than ten square metres in size, and one of the double rooms is just under sixteen square metres. The latest revisions to care standards make these rooms sizes acceptable, on the basis that these facilities were registered before the NCSC came into being. On the first floor of the home, there are several changes of floor level, which have to be negotiated, and a number of doorways have raised lips, which are a tripping hazard. This poses some limitations on the needs they can meet in terms of residents’ mobility. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one day in June 2005, and took 6.5hrs. It was facilitated by the manager and deputy manager. There were fifteen permanently placed residents and one resident in the home for respite care on the morning of the inspection: one other resident was admitted to a respite placement on the day of the inspection. The home is registered for 21 residents, but the manager advised that they normally only take 20. Six relatives has provided pre-inspection questionnaires, as had seven residents. Five residents were spoken to in some depth, and their records were tracked. What the service does well: What has improved since the last inspection? Good progress had been made on a large number of requirements made at the previous inspection. Only one of twenty-six requirements made had not been met, one other has yet to be evidenced. The home had started to act on the recommendations of an occupational therapist, that they had commissioned to advise on the building. A number of improvements had been made to the environment, including the reinstatement of an assisted bathroom. A maintenance schedule was in place. Staff records, including criminal records Bureau checks were all found to be in order. More staff had been recruited to undertake NVQ2. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 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. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 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 Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Residents can expect to have a needs assessment before being placed at the home, and to receive good written information on the service provided. EVIDENCE: A revised Statement of Purpose was provided which included the small number of amendments identified as being required at the last inspection. Room sizes, excluding en-suite had been included, plus details of en-suite facilities. This is important, as some rooms are not suitable to admit wheelchair users to. The complaints procedure detailed in the Statement of Purpose had a timescale included. The statement regarding the range of needs that the home meets clearly states that it does not provide care for those with a diagnosis of dementia. The document clearly states that the home has a no smoking policy. A revised Service User Guide was provided which included the small number of amendments identified as being required at the last inspection. The Statement of Purpose contains a summary of a recent resident survey, and a copy of the home’s terms and conditions. A copy of the terms and Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 9 conditions were seen on a resident’s file selected at random. It was not ascertained whether the home had a set of terms and conditions for persons receiving respite care – this will be checked at the next inspection. One resident spoken to who had been at the home just a few months confirmed, “I had a Residents’ Handbook” (Service User Guide). The files of two residents admitted since the last inspection was seen to contain a single assessment and a pre admission assessment undertaken by the home. Three residents asked had not visited the home prior to moving there. One said that their social worker chose it for them, one came in for respite care and stayed, another said that they did not know that anyone did visit. The manager advised that the home encourages people who are thinking about living at Westhorpe Hall to visit in the first instance, and this is stated in the Statement of Purpose. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Residents can expect to be well cared for, and to have their health needs met. EVIDENCE: A relatives written comment was “ more than satisfied, excellent care.” A resident spoken with said “They are all nice to me, they all treat me with dignity and respect.” Another commented, “They give me the impression they really like me as a person.” The care plans seen had implicit, rather than explicit goals. There was however good evidence of the home working to assist residents make improvements in key areas. The home had worked with a Community Psychiatric Nurse and psychologist with one resident. This resident was very much improved in their confidence and state of mind, and was participating well in the life of the home having previously been quite unhappy and depressed. This resident commented, “The girls have been very good to me, their patience and all that.” This resident had improved to the extent that they were now on a waiting list for sheltered accommodation. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 11 Four residents’ files inspected contained care plans that had been reviewed at monthly intervals, one was not yet due. The files contained appropriate manual handling risk assessments, and on one a continence assessment. Risk assessments signed by the GP and resident’s family members were seen to be on file for three other residents who had bedsides. The deputy manager confirmed the information on the pre-inspection questionnaire, that no residents had pressure sores. The home did not have a policy for pressure area care. The administration of medication was observed, and the practice was seen to be good, except in one instance when the career did not observe the tablets being taken. They advised that this resident was quite reliable. The deputy manager advised that no one self medicates at present, although the policy was seen and does allow for this. Medication Records were inspected and were all correct and complete, and the returns record was also accurate and complete. Controlled drugs were checked and found to be correct. One resident’s written comment was “ I don’t think there is a better place anywhere in the area because the staff are so very caring.” A recently admitted resident described the health input they had received or were expecting: “ Soon after I came here I had to see the doctor. I’m waiting to see the chiropodist and I understand the have put me down to see the optician when he visits.” Another resident had a number of health problems, and had improved considerably since they had been in the home. They described the homes prompt action in getting a doctor in when they were unwell. All residents’ medication and basic health is reviewed annually. A resident spoken with said that they had two baths a week, which they really enjoyed. “A carer helps me. They have a hoist, they do my back then they leave me to do the rest and I ring for them.” Another said they had one or two baths a week. One resident, when asked about privacy replied, “ Oh yes, they are good at that. When I used to go to the bank they did all that was necessary and then left me to it.” A requirement was made at the previous inspection that the Responsible Persons must ensure that resident’s wishes in terms of funeral arrangements are elicited and recorded in their care plans, in line with the home’s policy. The manager had advised that this had been done wherever possible, and files seen confirmed this. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents can expect to be encouraged to participate in the daily life of the home, and to have their daily living preferences understood and supported. Residents can expect to have a well-balanced appetising diet. EVIDENCE: A resident spoken with described how their two visitors were made to feel very welcome. “They say how friendly it is.” Another said that their visitors were offered a cup of tea, and that they could see them in their own room if they wanted to. One resident spoken to who had been at the home a few months. They would liked to have remained in their own home but recognised it was too dangerous for them. This resident said, “ This is a very good place, very kind and helpful, they couldn’t be kinder or more helpful, I don’t think I could find better. They se what you need, they see what you are interested in and go out of their way to get you involved, sewing on name tags, folding linen, knitting. (One of the carers) took me out for a ride round the garden this morning and we picked flowers for the tables, we usually go out, according to the season.” Another resident said that they get a walk around the garden with one of the carers. One resident confirmed that they took the notes of resident meetings, and another had drawn pictures for other residents. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 13 A list of the weeks planned activities was on display, which included bingo and games, cooking, walks – weather permitting, exercise in doors, hoopla and magnetic darts, and a weekly church service. A list of trips was also posted, including shopping trips to supermarkets and trips to the zoo, to the Abbey Gardens, and to a wildlife park. Other residents commented; “You couldn’t find a better place than this, it is such a lovely place, everybody is so lovely to you and everything.” “I’m quite content, I don’t worry about anything, I go to bed when I like, I get up at a reasonable time. The home had a nutrition policy which states that the home will cater for special diets when necessary, and states that residents will be weighed on admission and at regular intervals. It also states that residents’ wishes of where to partake of their meal will be upheld wherever possible. On the day of the inspection one resident chose to have their lunch in the lounge, the others all ate in the dining areas. Six of the residents who provided pre-inspection information confirmed they liked the food, one said they sometimes did. Another resident asked about the food said simply, “I love it.” The day’s menu was displayed: soup or grapefruit, crispy sardine slices with new potatoes, rice pudding or knicker-bocker glory. The meal did look appetising, and the rice pudding was home made. One resident choose an alternative and had baked potato and cheese. Menus seen provided a good range of wholesome food. One resident commented, “Oh the food is very good indeed, I didn’t expect that. Nice fresh home cooked food it looks nice, very appealing. You can say if you don’t like it, they will get you something else. There’s always a choice of desserts. Tea is at 4.30, a cooked snack, cheese on toast, spaghetti, cheese and biscuits. They come round at 8pm with a snack, buttered toast or a sandwich sometimes. I am eating more than I was at home, I was weighed last week and I’ve put weight on. I was getting a bit too thin at home.” One relative’s written comment was, “ ………... invited all the family to………..…’s party and laid on food at a time when we could come.” Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Residents can expect to have a number of formal channels through which they can make the views and any dissatisfactions known, including a well publicised complaints policy. EVIDENCE: The home had a complaints book which was viewed and found not to contain any complaints. A complaint had been dealt with by the home in 2005, and the Pre inspection questionnaire detailed one complaint. A resident spoken with was able to describe how to complain, but added that they hadn’t heard any complaints at all.” Advice on how to complain or make a suggestion was on the wall in large print. The home has a suggestions box; the manager advised that residents had never used this, but that staff do and they had received some useful suggestions. Two residents spoken with confirmed they had received postal votes. The home had an appropriate whistle-blowing policy, and a comprehensive Protection of Vulnerable adult’s policy which was reviewed earlier in the year. The deputy manager had a good knowledge of the policy and advised how policies were implemented, in such a way that staff would be aware of any new policies or changes. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Residents can expect a homely and attractive physical environment, which whilst not best suited to their needs, has been reviewed by an Occupational therapist, and whose recommendations have been or are being implemented. EVIDENCE: “The surroundings are beautiful” The house is also very homely and attractive, although not best suited for its purpose. The home had commissioned an Occupational Therapist (OT) to assess the environment. They had made a number of recommendations which the manager and assistant manager reported as having found helpful, and which the home had actioned or were actioning. These included grab rails in communal toilets and the extension of a half step outside of a fire exit so that a walking frame could fit onto it. Non-slip flooring had been recommended in all bathroom and toilet areas; the home had not completed this but advised that they intended to during the refurbishment programme. Shrubbery had been cut back in the garden. The OT had also recommended a loop system, which had not been actioned at the time of the inspection. Otherwise all specialist equipment was in place. One Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 16 resident had a pager/prompter to help motivate them to do things for themselves; the home had co-operated with a psychologist in setting up this facility. Grab rails had been put in a communal W.C on the OT’s advice. Time was spent with a resident in their own room, and they were seen to have two comfortable chairs and a locked drawer as required. Another resident spoken with confirmed that they could lock their room, but choose not to, and that they had a lockable drawer. The inspector was advised that the electrician had attended to do a five yearly electrical check, as had been required following the previous inspection. They were further advised that no electrical work had been required following this, but that the certificate had not yet been received by the home. There are two working bathrooms on the first floor, one of these is assisted and had been reinstated since the last inspection. The home also has an assisted bath on the ground floor, and a shower on the ground floor. Eight of the single bedrooms have en-suite toilet facilities as does one double room. The remainder have wash hand basins. None of these have en-suite showers. A high level latch had been fitted to the staff W.C. to prevent residents accessing this room, where the water had previously been found to be excessively hot. The thermostatic valve for the first floor bathroom had been reset and hot water was at a suitable temperature. A requirement had been made at the previous inspection that the ambient temperature of the back sitting room should be maintained at an appropriate level. The manager had planned to achieve this before the cold weather set in, by installing additional electrical heating. All radiators in the home were covered. There was an odour in one room, although the manager advised a new carpet had been fitted. Otherwise the home was clean and odour free. One resident said, “my friend used to be a health visitor, she commented that it doesn’t smell like an old people’s home. They keep sparklingly clean, any sort of odour or anything is dealt with at once.” Paper towels and liquid soap was available in all bathrooms seen, and no material towels in evidence in bathrooms. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Residents can expect to be protected by the homes recruitment procedures. EVIDENCE: The manager and owner advised that a recommendation that a minimum of 3 care staff should be on duty at all times during the waking day to ensure all the care needs of residents can be more comfortably met cannot be met with current levels of funding. The current minimum staffing levels are two carers on duty at all times; it has been agreed that this should increase to 3 if there are 21 residents. The home was adequately staffed on the day of the inspection. One resident commented, “I’ve never had to wait for more than a few minutes for any sort of help.” Staff files for the two most recently employed members of staff were inspected, and found to have all required documentation in place, including Criminal Record Bureau checks obtained before they commenced work. CRB checks were seen in place for all staff recruited since the last inspection. A CRB check was in place for the handyman working at the home. The home did not have a policy on the recruitment and use of volunteers, but a CRB was also in place for the one volunteer working at the home. Records showed that the seven most recently recruited staff had received induction training, either at Kerrison or by another training provider.8 care staff had either achieved their NVQ’s at level 2 or were in the process of being registered at Suffolk College. The home had 14 carers, and this initiative would bring the home up to the correct proportion of qualified staff. There was some Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 18 uncertainty about whether this could be achieved by the end of 2005. Update training had been booked for the deputy manager in Training Manual Handlers, and a schedule planed to update all carers, starting in July. Residents spoken with confirmed they felt confident when being assisted by care staff. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 A business plan which shows how residents’ interests are represented and furthered was not available, however, there is evidence in the home that residents can expect an open environment where their views are sought. EVIDENCE: The Registered Manager holds a Diploma in Care Services at level 4. Succession planning had taken place, and it is intended that an application will be put to the CSCI for the current deputy manager to be registered as manager. The manager advised that the deputy manager has achieved the Registered Manager’s training award. The home has an anti racism policy and a Harassment and Bullying policy. The results of the latest Quality Assurance exercise had been collated and published within the Statement of Purpose. A resident said that they had been to a resident meeting and proposed outings and amenities. “It was useful, you Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 20 felt that you were kind of part of it.” Minutes of a resident meeting held in May showed that six chose to attend. and that they were asked to contribute agenda items. The next meeting was to be held in July 2005. One of the residents confirmed that they still did the minutes for these meetings. A schedule was provided that included the dates of care staff supervision, which was in line with the standard. Recorded supervision was on file for two staff checked at random, it covered all main areas required, and focused appropriately on residents’ goals. An appraisal was also on one of these, the other having not been in post long enough for this to take place. The schedule did not include the deputy manager. The manager and the deputy confirmed that they work closely and openly but that the deputy does not receive formal supervision. The home was able to provide correspondence regarding ongoing lease arrangements, but does not have yet have a business plan which demonstrates how it will continue to meet residents’ needs and develop its service in line with residents’ interests. The manager advised that a new system had been put into place for residents’ monies, and a there was a new policy that complies with regulation 20, and the home had an appropriate policy regarding gifts and tokens from residents. The manager advised that the home no longer receives valuables for safekeeping, as stated in the policy, residents all have a locked drawer. Banking details were not inspected on this occasion. Door guards had been fitted to two residents’ room doors who required to have their doors left open. Fire training had occurred in February for all day care staff, and regular update training had been planned. A maintenance schedule was seen which included weekly, monthly and quarterly requirements. The fence around the moat, which was seen at the last inspection to be in some disrepair, had been made good. The home had an appropriate policy for the control and storage of substances hazardous to health that had been recently reviewed. The locked cupboard for storing products was seen, however, a cleaning product was in the kitchen that should have been locked away. The home’s accident book was inspected, and two residents who had had a number of falls were seen to have had falls risks assessments. Food stored in the refrigerator was seen to be covered and dated after opening. Temperature logbooks were maintained for the fridge and freezer and for cooked meats. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 21 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 3 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 2 3 3 X 2 Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 22 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 2 Standard OP8 OP9 Regulation 13(4)(c) 13(2) Requirement A policy for pressure area risk assessment and care should be in place. The Responsible Persons must ensure medication administered is observed to be taken, unless the resident has been risk assessed to self medicate. The complaints log must be accurately maintained. The Responsible Persons must forward a copy of a current electrical wiring certificate. The home must be kept free of unpleasant odours. Cleaning products must be kept in the cupboard for substances hazardous to health. Timescale for action 31/12/05 20/06/05 3 4 5 6 OP16 OP19 OP26 OP38 7(2) Schedule 4 23(2) 13(3) 13(4)(a) 15/12/05 15/12/05 20/06/05 20/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000024524.V269535.R01.S.doc Version 5.0 Page 23 Westhorpe Hall Residential Home 1 2 3 4 5 Standard OP2 OP7 OP20 OP34 OP36 The terms and conditions and residents’ views should also be within the Service User Guide. Goals on care plans should be clearly defined. The recommendations from the Occupational Therapist report should all be carried out. The Responsible Persons should provide a business and financial plan. A policy on the employment of volunteers should be in place. Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westhorpe Hall Residential Home DS0000024524.V269535.R01.S.doc Version 5.0 Page 25 - 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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