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Inspection on 26/09/07 for Westlands Care Home

Also see our care home review for Westlands Care Home for more information

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Residents generally receive a good standard of care and support and residents` and their relatives are happy with the care provided. Good systems were in place for the management of residents` medication helping to ensure that prescribed medication is available and administered. Information is provided which gives residents a clear idea what to expect as part of the daily routine. Routines are flexible and residents are asked about preferred times for getting up and going to bed. Staff take time to chat to residents, as they are assisting them and also when they have a spare few minutes. Comments in the surveys were positive about the food and residents` were enjoying their lunch time meal on the day of inspection. Visitors are also made welcome and the atmosphere is friendly and relaxed, which helps residents in maintaining relationships with friends and families. The current manager is experienced and comments from relatives indicate that they have been pleased that she has returned.

What has improved since the last inspection?

There has been an increase in the number of staff training for a National Vocational Qualification (NVQ), which provides staff with a basic understanding of the needs of older people and care practices which helps to ensure that staff are able to meet residents` needs.

What the care home could do better:

While there was evidence of an assessment process to gather information about residents` needs, it is important that staff training and experience is taken into account when considering whether to admit a new resident. This is to ensure that all of their needs can be fully met. Improvements to the risk assessment process are needed to ensure that the specific risks for the individual are properly assessed and managed. Particular ones highlighted were those for the use of bed rails. Advice was also given to review the risk assessment for smoking, again taking account of individual risks but also to ensure that restrictions on rights were not being unnecessarily placed. There had been an obvious deterioration in the thoroughness of the recruitment process and its adequacy in protecting residents. This appears to have occurred since the registered manager left in June 2007. The manager has now returned and is reviewing the recruitment process for staff employed in her absence in order to ensure that residents` are protected. The shortfalls in the recruitment process identify the need for more oversight by the organisation, particularly in instances where a manager leaves. A requirement has also been made about keeping The Commission for Social Care Inspection better informed about who is managing the home.

CARE HOMES FOR OLDER PEOPLE Westlands Care Home 48 Oxford Street Wellingborough Northants NN8 4JH Lead Inspector Kathy Jones Unannounced Inspection 26 September 2007 08:50 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 Westlands Care Home DS0000050657.V341159.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. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlands Care Home Address 48 Oxford Street Wellingborough Northants NN8 4JH 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) 01933 274430 01933 275882 westlands@regalcarehomes.com www.regalhomes.com Regal Care Homes Ltd Ms Tracy Burke Care Home 28 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (6) of places Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2006 Brief Description of the Service: Westlands is a care home providing personal care and accommodation for 28 older people over the age of 65 years. The home is currently registered to provide care for up to 28 older people with up to 22 older people with dementia. The home is owned by Regal Care Homes Ltd. The Home is situated close to Wellingborough town centre and local amenities, shops and the local park. There is a small courtyard area outside the Home, which is accessible to Residents and a garden, which is at present accessed by a flight of steps. Residents’ rooms are situated on all three floors of the building. A passenger lift provides access to part of the home however access to the majority of bedrooms is via at least one step. There are twenty single rooms with four having en-suite facilities and four shared rooms. The following fees are taken from the pictorial version of the service user guide dated September 2007: Fees range between £348.11 and £500 per week and are dependent on the room and an assessment of care needs. The main service user guide identifies that the fees include personal care, accommodation, meals, activities in the home and some outings. Chiropody and hairdressing services can be arranged and are charged separately. Other costs would include clothing, toiletries, some outings, telephone bills and alcoholic beverages. A copy of the most recent inspection report is also made available. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls and any complaints received. The report of the last main (key) inspection carried out on the 7th June 2006 was reviewed. An annual quality assurance self assessment (AQAA) submitted by the manager was reviewed as part of the inspection. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and the inspector spoke with residents’, visitors and staff during the inspection to ascertain their views. Feedback from residents’ was limited due to their dementia, however observations were made of interactions between them and staff and of their general well being. A sample of surveys received from relatives were reviewed during the inspection. Westlands had requested these as part of their quality assurance process. The management of a sample of residents’ medication was checked. And a sample of staff files reviewed to check the adequacy of the recruitment procedures in safeguarding residents’. Communal areas and a sample of residents’ bedrooms were viewed. Verbal feedback was given to the Manager throughout the inspection. What the service does well: Residents generally receive a good standard of care and support and residents’ and their relatives are happy with the care provided. Good systems were in place for the management of residents’ medication helping to ensure that prescribed medication is available and administered. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 6 Information is provided which gives residents a clear idea what to expect as part of the daily routine. Routines are flexible and residents are asked about preferred times for getting up and going to bed. Staff take time to chat to residents, as they are assisting them and also when they have a spare few minutes. Comments in the surveys were positive about the food and residents’ were enjoying their lunch time meal on the day of inspection. Visitors are also made welcome and the atmosphere is friendly and relaxed, which helps residents in maintaining relationships with friends and families. The current manager is experienced and comments from relatives indicate that they have been pleased that she has returned. What has improved since the last inspection? What they could do better: While there was evidence of an assessment process to gather information about residents’ needs, it is important that staff training and experience is taken into account when considering whether to admit a new resident. This is to ensure that all of their needs can be fully met. Improvements to the risk assessment process are needed to ensure that the specific risks for the individual are properly assessed and managed. Particular ones highlighted were those for the use of bed rails. Advice was also given to review the risk assessment for smoking, again taking account of individual risks but also to ensure that restrictions on rights were not being unnecessarily placed. There had been an obvious deterioration in the thoroughness of the recruitment process and its adequacy in protecting residents. This appears to have occurred since the registered manager left in June 2007. The manager has now returned and is reviewing the recruitment process for staff employed in her absence in order to ensure that residents’ are protected. The shortfalls in the recruitment process identify the need for more oversight by the organisation, particularly in instances where a manager leaves. A requirement has also been made about keeping The Commission for Social Care Inspection better informed about who is managing the home. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 7 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. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 8 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 Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 9 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): 1,3, Standard 6 is not applicable, as intermediate care is not provided. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process establishes the needs of prospective residents. However to ensure needs are fully met, this information should be judged against whether staff at the home have sufficient training and experience to meet assessed needs. EVIDENCE: Written information is provided in the form of a statement of purpose and a service user guide. These documents provide prospective residents and their families with clear information about the facilities, staff, and the care provided. The statement of purpose identifies that new admissions to the home would be on a non smoking basis, however a recent admission was a smoker. Advice was given to ensure that the statement of purpose reflects the practice. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 10 There are two versions of the service user guide. One of these is a simplified version, which includes pictorial prompts to aid understanding. The information is individual to Westlands and helps to give some idea about the routines of the home. There is also information about what is included in the fee and what is not. Copies of the statement of purpose and service user guide are made available to residents and their families. A copy of the most recent inspection report is also available, which helps people to make informed choices about their care. Review of the records for two newly admitted residents identified that prior to admission an assessment of needs is carried out. The assessment included gathering where applicable information in the form of an assessment from social services. In one case records showed that a resident with a diagnosed mental health condition had been admitted. The assessment confirmed that the residents physical care needs were greater than their mental health needs and therefore that he could be admitted within the current category of registration. However there was no evidence to show that sufficient consideration had been given, prior to admission, as to how the full range of the prospective residents needs could be met by staff. There was a lack of evidence that staff had sufficient or timely training/briefing about the specific mental health need to enable them to support the resident’s mental welfare. A sample check of residents’ care plans identified that information gathered as part of the assessment process had been used to plan resident care with the exception of the mental health needs of one resident. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 11 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general care provided appears to be good and the majority of the care plans in place to support the care were reflective of residents needs. However failure to have appropriate care plans in place for mental health needs and risk assessments for the use of bed rails has the potential to put some residents at risk. EVIDENCE: Residents’ spoken with during the inspection were happy with the care that they receive. Westlands had recently sent questionnaires to relatives to check their views on various aspects of the service. A sample of the comments received in September 2007 confirmed that relatives were also happy with the care provided and included comments such as “I am extremely impressed with ---- and the care ---”. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 12 A sample of residents’ care files were reviewed to look at how their care is planned and supported. A random selection indicated that care plans were in place for all residents’ and where a risk had been identified risk assessments had been completed. Care plans are important documents in providing information to care staff about the actions that they need to take to meet the assessed needs of residents’. This helps to ensure that residents get the care that they need. Some care plans were very detailed and appeared to be reflective of residents’ individual needs and gave good clear information for staff. Information about residents’ preferences as well as their physical care needs was included. However there was no care plan in place to guide staff in meeting the mental health needs of a resident and in one case there was conflicting information in different plans making it difficult to establish the resident’s needs. Records indicate that residents’ physical health care needs are monitored and that advice and visits are requested from General Practitioners and District Nurse’s where appropriate. Records are kept of the reasons for the visit and any outcome, including advice given. This helps in tracking any changes and meeting residents’ health care needs. Risk assessments were carried out to identify specific risks such as nutritional risks or pressure ulcers. Information based on the assessments about any required actions by staff was then transferred to the care plans. One resident’s records showed that bed rails were being used, however the current document titled risk assessment for the use of bed rails includes a list of statements such as “ensure the bed rails are appropriate to the bed” rather than actually assessing the individual risk. There was also no evidence of authorisation by a health professional such as a District Nurse. Good systems for the management of medication were in place. A sample check identified that residents’ prescribed medication was available with records to confirm administration. An audit of medication is carried out be an area manager during visits to the home, which helps to identify any poor practice and safeguard residents’. Observations during the inspection identified that staff spoke to and treated residents’ with respect. Westlands Care Home DS0000050657.V341159.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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visitors are encouraged and welcomed into the home and residents’ are happy with the quality of food provided. Routines are flexible and allow residents’ choices in their daily lives, however practice needs to be reviewed to ensure that rights are not unnecessarily restricted. EVIDENCE: The pictorial version of the service user guide describes the general routines of the home and sets out what happens in a typical day. Observations and discussion with staff and residents’ confirmed that the routines are flexible and take account of residents’ needs and preferences. The annual quality assurance self assessment submitted by the Registered Manager states that “activities are currently arranged by the Acitivites Organiser and on an ad hoc basis by staff, relying on the choices made by residents. There is a list of activities to help prompt staff and service users as to possible options. Staff interact with residents throughout the day chatting, Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 14 reading newspapers, magazines, helping with puzzles, giving manicures and hand massages etc”. Observations and records confirm that this is the case. The manager advised that some residents’ had recently been enjoying going across to the local pub for a drink and a game of skittles. A resident confirmed that they enjoy going out. ‘Mr Motivator’ was due to visit the day after the inspection to encourage residents’ with some gentle excercises which help to amintain mobility. There was evidence that choice is promoted throughout daily life, and that individual preferences are identified in residents’ care plans. Advice was given to ensure that a detailed risk assessment supported the need to remove a resident’s cigarettes at night as this could be considered a restriction on their rights. There was a risk assessment in place, however there was insufficient infrmation to determine the actual risk. Residents’ were observed to enjoy their lunch time meal and said that the food was good. There was a choice of liver or chicken casseroles which were home made, nicely presented and tasty. Residents’ are offerred a choice of meal and the choice is given at mealtimes, rather than in advance to avoid a situation whereby residents’ forget what they have chosen. The cook is working on some visual aids to assist residents’ with dementia further with making choices. A visitor confirmed that the visiting arrangements are flexible and they are made welcome. Staff welcomed visitors on arrival. Westlands Care Home DS0000050657.V341159.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 (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. There are procedures for dealing with concerns and complaints which relatives/visitors are aware of, which helps to protect residents’. EVIDENCE: The Commission for Social care inspection has referred two complaints to social services for investigation since the last inspection in June 2007. Both complaints related to the care of individuals funded by social services. The investigation of one of the complaints had not been concluded at the time of this inspection. One other complaint relating to staffing levels was referred and investigated by the provider. No evidence was found to support the complaint. A complaint was received directly by the manager about a staffing issue. Records indicate that complaints are taken seriously and investigated appropriately. Information is available to residents’ and their families about how to make a complaint in the service user guide and information reviewed in the surveys carried out by Westlands confirm that people know how to raise concerns. Staff receive training in safeguarding vulnerable adults from abuse and understand their responsibilities for the people in their care. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable and in good decorative order providing a pleasant environment for residents. EVIDENCE: The Home is situated close to Wellingborough town centre and local amenities. Some residents have recently enjoyed visits to the local pub, which is just across the road from Westlands. There is a garden, which is accessed by a flight of steps and therefore not easily accessible to the majority of residents. However there is a small courtyard area where flower tubs are planted, which some residents use when the weather is good. Plans for improvement identified in the annual quality Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 17 assurance self assessment submitted by the manager that ramps were to be fitted to enable easier access to the garden. Communal areas consist of three lounge/dining rooms. The rooms are comfortable and homely. Residents’ rooms are situated on all three floors of the building. A sample check of rooms identified that they were clean and comfortable. A passenger lift provides access to part of the home however access to the majority of bedrooms is via at least one step. There are twenty single rooms with four having en-suite facilities and four shared rooms. The home was clean and cleaning programmes are in place to address any odours. The majority of staff have received infection control training and protective aprons, disposable gloves and alcohol gel are available for staff to reduce the risk of transfer of infection. The inappropriate storage of a night catheter bag, which had no protective cap in place, increasing the risk of infection, was discussed with the manager. Advice was given to obtain a Department of Health guidance document called ‘Essential Steps’ which is a risk assessment designed to help assess the adequacy of the management of infection control. Regular review of the risk assessment will help to identify any shortfalls and reduce the risk to residents. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff receive training to meet the needs of residents, however failure to operate a thorough recruitment procedure puts residents’ at risk. EVIDENCE: Observations and discussion with staff indicated that there is sufficient staff to meet the needs of residents’. Positive comments were received in resident and relative questionnaires about the staff team. The annual quality assurance self assessment identifies that seventeen out of twenty one staff are trained or undertaking National Vocational Qualification (NVQ) level 2 or 3. The NVQ training provides staff with a basic understanding of the needs of older people and care practices which helps to ensure that staff are able to meet residents’ needs. A staff member spoken with confirmed that they are provided with approriate training to help meet the needs of residents’. There is an induction programme in place which includes an initial three day induction and a skills for care twelve week induction. A sample check of files for three recently recruited staff was carried out to check the adequacy of the recruitment process in protecting residents’. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 19 Serious shortfalls in the recruitment procedure were identified with evidence that staff had started work without proper checks being made which has the potential to put residents’ at risk. This included staff starting work prior to receipt of a criminal record bureau clearance with no evidence of any systems to safeguard residents. Checks against the protection of vulnerable adults register made after staff started work, unexplained gaps in employment history and in one case the only references were from a relative and a friend. Records for one member of staff indicated that they did not have current permission to work in the country, however the manager has confirmed that, since the inspection additional more up to date documents have been produced. All three staff were recruited during a period where the current manager had left the employment of the company. The manager is reviewing the recruitment process for staff employed in her absence in order to ensure that residents’ are protected. As previous inspections have identified a thorough recruitment process there is evidence that the organisation needs to review their arrangements to ensure that residents are adequatley protected when a manager leaves. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 20 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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the current management is good, better arrangements and management oversight are needed to safeguard residents in the event of management changes. EVIDENCE: The Registered Manager is experienced in caring for older people and has achieved a National Vocational Qualification Level 4 in Management and the Registered Managers Award. Comments from relatives seen in the surveys, which are part of Westlands quality assurance, confirm that the current management arrangements are good and include “better now Tracy is back”. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 21 It was identified that the current manager was registered manager at Westlands up until she left to work for another organisation on 8th June 2007. The Area Manager has informed us that a letter was sent to the Commission for Social Care Inspection (CSCI) in May 2007, however we have no record of being formally notified of this or of the managers renewed employment starting on 10 August 2007. A statutory requirement has not been made on this occasion but advice is given to ensure in the future that CSCI have received notification of important events such as a registered manager leaving and of details of interim management arrangements. Therefore while the current management appears to be good, the organisation must implement systems to maintain management oversight, particularly in the event of the absence of a registered manager. Good management is considered to be crucial to the standards of care and well being of residents. As detailed in the staffing section serious shortfalls were identified in the recruitment process, which have the potential to put residents’ at risk. There was no evidence that the shortfalls had been identified through the organisations quality assurance processes. An annual quality assurance self assessment submitted prior to the inspection did not indicate an awareness of these vulnerabilities, which have become apparent during this inspection. The quality assurance process, involves seeking views from residents’, relatives and health professionals involved with resident care. A sample check of the comments received indicated that people felt confident in raising positive and negative issues. The process included acting on any identified shortfalls. A sample check of monies held on behalf of residents found that money was securely stored and balances were correct. There is a system whereby an area manager audits the management of residents’ finances periodically which helps to safeguard them. No health and safety concerns were identified during the inspection. Staff confirmed that they receive training in safe working practices including movement and handling and food hygiene. Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 22 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 3 Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 12 (1) (a, b), 14 Requirement Residents must not be admitted unless it can be determined that staff have the necessary experience and training to meet their assessed needs. This is to help ensure that proper provision for their health and welfare is made. Care plans must be in place to guide staff in the actions that they need to take to meet all residents’ assessed needs including mental health needs. Prior to bed rails being used, a thorough assessment must be carried out to ensure that the equipment is safe for the resident and suitable for the bed. Authorisation must also be obtained from an appropriate health professional. Storage of equipment such as catheter bags must be reviewed to reduce the risk of infection. Required checks and references must be carried out before staff start work, which would include criminal record bureau clearances, checks against the DS0000050657.V341159.R01.S.doc Timescale for action 30/11/07 2. OP7 15 30/11/07 3. OP8 13 (4) (c) 30/11/07 4. 5. OP26 OP29 13 (4) (c) 19 (1) (b) schedule 2. 6 30/11/07 30/11/07 Westlands Care Home Version 5.2 Page 24 protection of vulnerable adults register, references and gaps in employment history. This is to help safeguard residents’. 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 Refer to Standard OP14 Good Practice Recommendations Practices such as removing residents cigarettes at night should be reviewed and actions taken based on a risk assessment, which takes account of the individual. This is to ensure that residents’ rights are not unnecessarily restricted. Quality assurance systems should be reviewed to ensure that they are robust enough to protect residents through identifying shortfalls in areas such as the recruitment process. 2 OP33 Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Westlands Care Home DS0000050657.V341159.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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