Inspection on 11/09/06 for Westlands

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westlands 12/11/07

Westlands 10/08/05

Westlands 26/05/05

Westlands 01/11/04

Westlands 20/05/04

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Southfields

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

CARE HOME ADULTS 18-65 Westlands Westlands West Hill Road Woking Surrey GU22 7UL Lead Inspector Pauline Long Key Unannounced Inspection 11th September 2006 10:00 Westlands DS0000013823.V311252.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 Westlands DS0000013823.V311252.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. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlands Address Westlands West Hill Road Woking Surrey GU22 7UL 01483 761067 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) Whitmore Vale Housing Association Mrs Janika Calleja Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. It is a condition of registration that of the 7 Residents accommodated 1 RESIDENT MAY BE OVER THE AGE OF 65 YEARS. 26th May 2005 Date of last inspection Brief Description of the Service: Westlands is a large detached house in a residential street within walking distance of the centre of Woking. It is on two floors, having five service users bedrooms on the first floor and two further service users bedrooms on the ground floor. Also on the ground floor is a large communal sitting/dining room, kitchen, utility room, activity room, sensory room, smoking room, toilet and office. Outside is a well-tended garden, with two terraced areas for outdoor entertainment, which is enclosed by a wooden fence. To the front of the home is a car parking area. Westlands benefits from having easy access to all the public services in Woking town. The service users catered for at the home are a group of seven men with learning disabilities, who were previously cared for in a long stay hospital. The fees at the home range from £1201.00 per week to £1396.00 per week Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of the key inspection and was unannounced. It commenced at 09.15, and ended at 15.45. Discussions were had with the residents, manager, staff and a visitor to the home. Documents sampled, included service users files, care plans, staff records, and the pre-inspection questionnaire. Four comment cards were received at the CSCI office from relatives and feedback is included in this report. A full tour of the home and garden took place. Verbal feedback from the resident’s at home on the day was limited, in view of the their communication difficulties. However observations of body language, facial expressions and sounds and interactions with staff, evidenced a state of general wellbeing. The CSCI would like to thank the residents, manager and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements are required in staff training as one member of senior staff has not undertaken any statutory or good practice training since employment commenced. Improvements are also required in respect of training records, as Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 6 the inspector was unable to evidence that a member of staff had undertaken safeguarding adults training. The property presents challenges for the providers in respect of the ongoing need for updating and refurbishment. The fabric and furnishings of the building were satisfactory, although the communal areas will require updating in the near future. A mattress on one of the service users beds was in poor condition and must be replaced. A programme of renewal and maintenance must be produced. Whilst the home holds residents meetings in order to seek their views, there was evidence to suggest that the last service user survey was distributed to relatives and representatives in 2002, indicating that the home has not sought the views of other service users for some considerable time. Records indicated that the water temperatures in the home were inconsistent and at times not within safe levels. Attention must be paid to all of the homes water taps to ensure that residents and staff are safe. Improvements are required in respect of some health and safety issues. Hazardous substances were not stored appropriately, and posed a risk to the service users. The floorboards in the boiler room were unsafe and posed a risk to both service users and staff. One of the garden fence panels was broken and must be replaced. Requirements have been made in respect of these areas. Please refer to pages 26, 27 and 28 of this report. 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. Westlands DS0000013823.V311252.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 Westlands DS0000013823.V311252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information they need to make a choice about where to live. Improvements are required to ensure all service users in the home have access to this information. Arrangements are in place to ensure a full needs assessment takes place, indicating that the home would be fully aware of a residents needs. EVIDENCE: The home’s statement of purpose and service user guides were sampled and were produced in written and symbol/pictorial formats, and reflected the new management arrangements at the home. Discussions were had with the manager in respect of service users accessing these documents, as they were not evident in service users bedrooms. The manager commented that one service user would tear the document up and others may not understand it. At the time of the site visit the manager stated that he was reviewing the arrangements in respect of this issue. All of the service users at the home have been resident at the home since it opened in 1995. Service users files were sampled and evidenced that comprehensive care needs assessment are carried out, to include all aspects of daily living, giving the reader a good insight into a service users identified needs. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 9 Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual care plan, where their assessed and changing needs and goals are reflected. Service users are encouraged and supported to make decisions about their own lives and to take responsible risks. EVIDENCE: Care plans were sampled, and were found to be good, with plans around all daily living activities. The care plans gave instructions and guidelines to the reader about a service users care needs and action plans as to how these needs could be met. Risk assessments were clearly documented and guidelines in place to minimise the risks. Some reviews were noted. Discussions were had with the care staff in respect of service users reviews, they commented that care plans and care needs would be reviewed on a six monthly basis unless there was a change of need before the next planed review. The manager has produced an action plan, which includes a review of all care plans. The manager and staff were observed supporting the residents in respect of decision making and choices for example, choices for lunch and activities. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 11 Service users were observed coming and going from the kitchen helping themselves to drinks, care staff observed the service users from a distance, promoting service users independence but ensuring they were taking responsible risks. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager and staff enable the service users to maintain fulfilling lifestyles in and outside the home, and promote contact with family, friends and the local community. The meals at the home are wholesome, nutritious and appealing. EVIDENCE: None of the service users at the home undertake paid employment. The manager discussed improvements in the arrangements for the provision of activities outside the home; for example, arts and crafts, half hour walks every day, trips to the beach, art visits to Guildford, music and verse, cookery adult education classes, pots and plants, PIPS (Promoting Independence) classes and visits to the sensory suite in a nearby local authority facility. All of the service users went on a five day holiday earlier in the year. The manager discussed his training plan in respect of shallow water safety, in order that care staff from Westlands can accompany some of the residents to the local swimming pool. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 13 The home has a small sensory and activity room where service users like to spend time. The home also provides a smoking room for those service users who like to smoke. The home is committed to ensuring that the service users maintain their relationships with their family and friends. Some of the service users receive regular visitors and keep contact by phone. A visitor to the home commented that the home and staff were very welcoming. A relative commented, “the staff are like real friends, they are helpful and always have a warm greeting for all the visitors, they really do care A lunch time activity was observed. Service users were encouraged and supported to get the dining table ready for the meal. All of the service users sat up at the dining table and were joined by care staff, who were also eating their lunch. The deputy manager commented that this helped to provide for a more social occasion for the service users and staff. Care staff supported those service users who required help with their meal offering encouragement, this support was offered in a familiar yet respectful manner. The meal time was quite lively, with lots of noise reflecting that of any other household. All of the service users appeared to enjoy their lunch of freshly made sandwiches and soup. One service user commented that he enjoyed his lunch and promptly proceeded to clear the dishes away. The menus at the home were sampled and evidenced a varied choice for the service users. Staff commented that the service users are encouraged to discuss the menus at the home. The kitchen although dark was clean and tidy. Kitchen practices and procedures were sampled and were found to be good. The fridges, freezers and cupboards were well stocked with fresh, frozen food, fruit and vegetables. Food was stored appropriately and according to food hygiene regulations. Good records were kept in respect of fridge, freezer and food temperatures. Westlands DS0000013823.V311252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff have a good understanding of the service users support needs, this was evident from the positive interactions and relationships observed. The health needs of the residents are well met. Improvements are required in respect of keeping relatives and representatives informed about their relative. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Care plans included clear guidelines on any support each service user required with personal and health care. Physical and emotional needs of the service users were also detailed in the care plans and daily records, which included visits to the doctor and hospital appointments. Comments from a relative indicated that they were not always kept informed of important matters affecting their relative, nor were they always consulted about their care. Staff, were observed supporting the service users with various aspects of daily living, this support was offered in a sensitive and respectful way. None of the service users in the home administers their own medication. Discussions were had with the care staff on duty and evidenced that they were aware of the policies and procedures regarding medication. They described the training they received and commented that only those staff who had been assessed as Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 15 competent were permitted to administer medication. Medication record sheets were checked, and were found to be properly completed, with no gaps in signatures noted. Since the last inspection eleven errors in medication administration have been notified to the CSCI, several of which were in respect of one service user. These errors have being dealt with according to the homes medication and disciplinary procedures. Discussions were had with the manager around covert administration of medications and the need to develop guidelines and protocols for one service user in respect of his medication. There were documented protocols and guidelines in place for PRN (as required) medications. Medication storage was sampled and found to be good. There were records to evidence regular medication audits. A recommendation was made in respect of keeping families informed. Please refer to pages 26,27 and 28 of this report. Westlands DS0000013823.V311252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the service users. Improvements are required in respect of safeguarding adults training, to ensure all staff have an understanding of these procedures and that service users safety and wellbeing are protected. EVIDENCE: CSCI has received no complaints about this home since the last inspection. No complaints have been received at the home. Discussions were had with the care staff around the homes complaints procedures and they demonstrated a good understanding of the procedures. Comments received from two relatives indicated that they whilst they had never made a complaint they were not aware of the homes complaints procedures. One safeguarding adult referral has been made since the last inspection. Meetings have been held in this respect and the issue has been satisfactorily resolved. Discussions were had with care staff in respect of the homes safeguarding adults procedures and various scenarios were put to them in respect of abusive situations, it was positive to note that they had a good understanding of the safeguarding adults and whistle blowing procedures. The organisation is proactive in respect of safeguarding adults training. All of the care staff interviewed commented that they had undertaken this training. It was a concern therefore, that there was no documented evidence in respect of one particular member of staff having completed this training. This was discussed with the manager at the time. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 17 A requirement and a recommendation have been made in respect of these areas. Please refer to pages 26,27 and 28 of this report. Westlands DS0000013823.V311252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,2526,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is satisfactory, clean and hygienic and meets the needs of the service users. Attention must be paid to the furnishings and decoration in all of communal areas and to the garden fence to ensure the service users benefit from a more pleasant and well maintained and safe environment. EVIDENCE: Westlands is an older property and therefore presents challenges for the providers in respect of the ongoing need for updating and refurbishment. The furnishing and decoration in the communal areas require review. The furniture in the lounge area is domestic in design, however observations of service users behaviours for example dropping/throwing themselves into the armchairs and sofa indicates that the home would benefit from more robust seating. The covers on the seating had been washed and had shrunk, which was unsightly. The dining room tables were appropriate but some of the dining chairs were not. The paint work on the walls although dull was satisfactory, but the paintwork on the fire place was badly chipped, which did not enhance the environment. It was positive to note that some of the floor coverings had been Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 19 replaced. The carpet on the upper floor landing will require attention in the near future as it was soiled and looked worn in places. One relative commented, “that she was very pleased with the home, it is such a lovely home, it is always clean”. The service users bedrooms were clean and tidy and there was evidence of many personal items. Rooms contained many sensory pieces of equipment which were good for those service users with communication difficulties. It was positive to note that one of the bedrooms benefited from assistive technology, promoting a service users independence. The beds and mattresses were checked and one was found to have a hole in it. The others were found to be in satisfactory condition. There was no hand drying facilities for care staff in the service users bedrooms. The boiler room door was open and this presented a hazard to the service users and staff as some of the floorboards were broken. The garden will also require attention in the near future. One fence panel had been damaged and should be replaced. It should be noted that the manager had already identified many of these issues and has included some of them in the action plan submitted to the registered provider. Requirements and a recommendation have been made in respect of these areas. Please refer to pages 26,27 and 28 of this report. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the recruitment practices at the home. The home employs an efficient and trained staff team in sufficient numbers, who provide a good quality of care to the service users. Improvements are required in respect of all staff undertaking statutory training and in staff supervision. EVIDENCE: The home employs a diverse staff group. There were 3 care staff, and the deputy manager on duty on the morning shift providing care to the service users. Extra staffing has been put in place to meet the needs of one service user. The dependency levels of the residents on the day indicated that the present staffing ratio was adequate. The manager stated that recruitment was ongoing and whilst the home has to use agency staff, continuity is maintained by using the same staff, who, are familiar with the service users. One member of agency staff commented that she had worked at the home for almost a year. Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Staff were observed going about their work in a confident and professional manner. Two new members of staff including the manager have been employed at the home since the last inspection. Staff recruitment files were sampled and Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 21 evidenced good recruitment practice, with all of the appropriate checks carried out and documentation in place. Discussions were had with the care staff on duty. They stated that they are offered many opportunities to attend statutory training and other training in line with current good practice, the homes training records evidenced this. It was a concern to note, that one member who commenced work in late 2005 had not undertaken any training. It should be noted that the new manager has identified this shortfall and has arranged for all statutory training to be undertaken by this member of staff. Two members of the staff team have completed an NVQ (National Vocation Qualification) and the manager has plans for a further two to undertake one. Seven of the staff team hold a first aid certificate. There is a formal one to one staff supervision programme in the home. However since the previous manager left the deputy manager has been unable to achieve the required number due to increased workload. Records were sampled and evidenced that some of the staff had received some formal one to one meetings with the deputy manager. The new manager has also carried out some one to one meetings with staff. There was also evidence of a staff meeting on 05/05/06. A further staff meeting has been arranged for 22/09/06. Requirements have been made in respect of these areas. Please refer to pages 26, 27 and 28 of this report. Westlands DS0000013823.V311252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the ethos, leadership and management approach of the home and their views are listened to. Improvements are required in respect of the systems in place for evaluating the quality of the services provided at the home. Improvements are required in some areas and practices to ensure the health, safety and welfare of service users is promoted and protected. EVIDENCE: There have been changes in the management arrangements at the home since the last inspection. The new manager has been in post since July 2006. Discussions were had with the registered provider in respect of an application for registration with the CSCI. The manager is experienced and has a good understanding of the needs of the service user group. He was observed interacting with service users and staff and had an open and inclusive style of management. Discussions with care staff indicated that they had confidence in Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 23 his abilities and that they were optimistic for the future. The manager has already identified various areas for improvements at the home and has submitted an action plan to the registered provider in order to progress these improvements. Staff discussed the meetings held at the home where service users are supported and encouraged to air their views. The minutes of the most recent meeting held on the 23/07/06 were sampled. Health and safety checks are routinely carried out at the home and clear records kept. The water temperatures in some of the rooms were sampled and were found to be satisfactory, however the records were checked and evidenced variations in temperatures. Water temperatures in excess of 58 degrees centigrade were recorded in the kitchen and laundry areas, some of the bedrooms/bathrooms were recorded as considerably lower that 43 degrees centigrade. The manager commented that water temperatures were taken in the morning and that he was going to vary the times in order to gain a better overview. On the whole hazardous substances were stored appropriately, however on the day a bottle of sanitizing gel was left in one of the upstairs bathrooms. The care staff, sleeping in room was open and contained various liquid toiletries and cleaners, which posed a potential hazard to the service users. No risk assessments had been carried out in respect of these liquids. Requirements were made in respect of these areas. Please refer to pages 26, 27 and 28 of this report. Westlands DS0000013823.V311252.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 3 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 2 X Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 YA23 Regulation 12(1)(a) 13(6) 12(1)(a) 13(6) 18(2)(a) Requirement The registered person(s) must ensure that all staff, undertake training in safeguarding adults. The registered person(s) must ensure that all staff undertake statutory training. The registered person(s) must ensure that all staff receive the required number of formal one to one supervisions with a manager. The registered person(s) must ensure that all hazardous substances are stored appropriately according to COSHH (Control of Substances Hazardous to Health) regulations. The registered person(s) must ensure that risk assessments are carried out on all liquid toiletries. Timescale for action 11/12/06 2. 3. YA35 YA36 11/12/06 11/12/06 4. YA42 12(1)(a) 13(4)(a(b(c 11/09/06 5. YA42 12(1)(a) 13(4)(a(b(c 11/10/06 Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 26 6. YA42 12(1)(a)13(3) The registered person(s) must ensure the regulation of water temperatures in all areas of the home in order to control the risk of Legionella and the risk from hot water. The temperature of the water in the home must be maintained close to 43 degrees centigrade. 16(2)(b) The registered person(s) must ensure that all service users have access to adequate bedding. The mattress in a service users bedroom must be replaced. The registered person(s) must ensure that all areas of the home are of sound construction and kept in a good state of repair. The floorboards in the upstairs boiler room must be replaced/repaired. The broken fencing panel must be replaced. The registered person(s) must ensure that home takes the views of service users and their representatives in to account and must establish and maintain a system for evaluating the quality of the services provided at the home. The registered person(s) must ensure that there is a planned maintenance and renewal programme for the fabric and decoration of the premises, with records kept. 11/10/06 7. YA42 YA26 11/10/06 8. YA24 23(2)(b) 11/11/06 9. YA39 24(2)(b) 11/11/06 10. YA24 23(2)(b(d) 11/12/06 Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA22 YA19 YA30 Good Practice Recommendations The registered person(s) should consider reminding the service users relatives and representatives of the homes complaints procedures. The registered person(s) should consider how best to keep service users relatives/representatives informed about their relatives changes in need. The registered person(s) should consider the appropriateness of the current arrangements in place for care staff and other visitors at the home to wash their hands whilst in a service users bedroom. Westlands DS0000013823.V311252.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Westlands DS0000013823.V311252.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. 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!