Inspection on 05/09/06 for Westlands House

This inspection was carried out on 5th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westlands House 26/01/09

Westlands House 29/11/05

Westlands House 29/07/05

Westlands House 16/12/04

Westlands House 25/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Westlands House Headmoor Lane Alton Hampshire GU34 3EP Lead Inspector Isolina Reilly Unannounced Inspection 5th September 2006 09:00 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 House DS0000012233.V310612.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 House DS0000012233.V310612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlands House Address Headmoor Lane Alton Hampshire GU34 3EP 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) 01420 588 412 Ms Lesley Linda Tagima Mr Anthony James Daly Ms Lesley Linda Tagima Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (33) of places Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than ten service users in DE(E) at one time. Date of last inspection 29th November 2005 Brief Description of the Service: The home provides accommodation for thirty-three older people over the age of sixty-five years. Within the thirty-three residents up to ten people with dementia. The home is owned and managed by Ms Lesley Linda Tagima. Westlands House is a former private residence that has been converted into a care home. The home is situated in large gardens, in a pleasant rural location on the outskirts of Alton, Hampshire. All resident’s bedrooms are single rooms with en-suite facilities. Residents have access to one large lounge, conservatory and separate dining room on the ground floor and a further quiet lounge diner on the first floor. The provider makes information available about the service, including a statement of purpose, service user guide and the commission’s report to prospective residents on request. Copies of these documents are available at the home and may be sent out by post on request. The owner confirmed during this visit that the fees for the home range from £327 to £560 per week for residential care. There are additional charges for hairdressing, chiropody, therapeutic massage, beautician, newspapers, magazines and toiletries. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over one day. The inspector looked around the home, viewed records and procedures spoke with residents, relatives, staff, the administrator and observed the interaction between them. The manager and assistant manager helped the inspector during the visit. The managers, staff confirmed that service users like to be addressed collectively as residents rather than service users. What the service does well: The home is good at assessing if it can meet the needs of residents before they come to the home and makes good records. The residents and relatives spoken with stated they had useful information about the home when making the decision to stay. Everyone spoken with confirmed that staff are caring, respectful and mindful of peoples need for privacy and dignity. There are good records kept by the home to help carers look after individuals. The carers are aware of residents’ needs and how to care for them. The residents have access to health care professionals that visit the home or by going out to see them in the community. The home provides organised activities and staff are able to spend time with individuals. The residents confirmed that they days are flexible and they can take part in the activities, games and entertainment put on by the home if they wish to. The home has an open and good process in place for dealing with complaints, concerns and compliments. The residents are protected from abuse by a staff team that a well informed about adult protection procedures. The staff team at the home is skilled and receive regular training to be able to care for the residents. The home has a logical and detailed process for recruiting new staff. There are good systems in place for making sure that the service is run in a safe manor for residents. The residents stated they all feel safe and comfortable at the home and their opinions are sought by the home. The organisation has a system in place for monitoring the quality of the service being delivered at the home. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good admission process, giving residents and their families clear information regarding the service that meets the needs of the individual. The home does not provide intermediate care. EVIDENCE: The residents spoken with explained that they and or relatives were able to visit the home before making their decision to stay. The relatives spoken with confirmed this. The manager and assistant manager visit the prospective client and undertake an interview with them and their family or carer. They complete a full assessment of needs and aspirations. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 9 Records of these completed assessments were seen on the files tracked. The managers have many years experience in assessing care needs and undertakes regular training to keep themselves up dated. Two out of the four residents records seen had a copy of the Adult Services care management assessment and the instructions to care staff mirrored those needs. Another resident’s file had a copy of a health care assessment prior to admission. The manager confirmed that all new residents undergo a full assessment of their needs and aspirations to establish if the home is able to meet them. These cover the necessary areas including, personal care, physical well-being, dietary preferences and records of regular weights. Information was seen on each file that described issues with sight, hearing, mouth and foot care. There was information on the level of mobility, dexterity and a history of falls, continence and behaviour. There were records of life history and relationships including likes, dislikes and preferences. The residents and relatives spoken with said that the home asked lots of relevant questions and looked after the residents well. Three residents spoken with were able to recall their admission stated that they were made very welcome. One said, “I am comfortable here and everyone is very pleasant” another resident said “I feel that this place is my own and I’m very happy here”. The four residents records seen contained signed contracts that were informative and contained all the necessary information. Two residents spoken with confirmed that the contract had been explained to them and their relatives when they first came to the home. The manager confirmed that the home does not provide ‘intermediate care’. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records of care within the home are detailed and clear enabling staff to meet residents’ personal and health care needs. The home promotes residents’ privacy and dignity. Medicine is administered, stored and handled appropriately by staff that are trained. EVIDENCE: Three out of the four resident files were discussed with each individual resident who confirmed that they were aware of the records the home holds on them and the staff have discussed their needs and care with them. The relatives spoken with confirmed this. In three of the care plans residents’ signatures were seen stating that their care plan had been discussed and drawn up with their assistance. The fourth care plan had the signature of a relative. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 11 All care plans seen contained written risk assessments and instructions to staff on how to look after the individual. The records also included names of relatives, friends, health care professionals and social services care managers who are involved in supporting the individual. The files had recently been reviewed by the key worker. There were details of monthly reviews and changes to care instructions recorded. Three staff spoken with were aware of residents care needs and the resident stated they receive the necessary support and care. The staff stated that they did use the care plans and found them useful. Records of doctor and nurse visits including information on outpatient, dental, optician and chiropractic appointments were seen on the files. The home keeps a log of all visits to the home by health and other professionals. Various residents stated that a visiting dentist and optician had seen them. The residents spoken with felt they are being well looked after by the home. They described staff as caring, helpful and appeared to know what they are doing. Three residents stated that staff were respectful, and mindful of their privacy and dignity. The inspector observed the staff interacting with the residents and found them attentive, caring, respectful and had a good understanding of individual’s needs. Refreshments and snacks for both residents and visitors were offered regularly throughout the day. A staff member was observed administering medication appropriately and there is a good medication policy and procedures. The home administers from a ‘nomad system’ provided by the local pharmacist and stored in the home’s utility room and in two separate medication trolleys securely stored one on each floor. The home’s medicines seen were stored in clean and reasonably orderly with medication stored correctly in date and in sufficient quantities. The senior carer confirmed that there are no residents who self administer their own medication and the home has no control drugs. A medication fridge is kept locked in the utility room and temperatures are regularly monitored and recorded. The assistant manager and a senior carer order and check all medicine received at the home recording name, quantity and sign for them. The records were seen and found to be satisfactory. The home uses the ‘Medicine Administration Record Sheets (MARS) system for recording the administration of medication. Each resident’s record also has a recent photograph and one on the ‘nomad box’. Medication that is in need of disposal is returned to the local pharmacy and a record is kept by the home that is signed on receipt by the pharmacist. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 12 The carers stated they have received training in the safe handling of medication and management monitor their competency regularly. The manager stated that only senior staff administer medicines once they have been assessed as competent. The senior carers have completed training in the safe administration and handling of medicines. Staff training records seen confirmed this. Westlands House DS0000012233.V310612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents experience a stimulating and varied life at the home and visitors are made welcome. The meals in this home are good and residents are given plenty of choice. EVIDENCE: The inspector observed residents reading books including some in large print, daily newspapers and magazines. Two residents stated that thy enjoy reading and were able to exchange their books at the library. Another resident was knitting. Two residents spoke with stated that enjoyed the activities and were especially looking forward to the visiting farm at the weekend. Visitors were seen coming and going throughout the visit and those spoken with stated that they felt the home catered for the individual residents’ needs and aspirations. The home employs an activities co-ordinator and is looking to find an assistant to expand the scope of activities available to residents. The activities co-ordinator Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 14 maintains detailed records of activities offered and participation by individuals. She also regularly consults with the residents on the type of activities they wish to participate in. The records showed that many residents took part in quizzes, regular exercise programmes, ball games, word games pass the parcel, dancing, balloons, skittles, football games, chats, and arts and crafts. Posters of forth coming events were placed around the home and a list of organised activities was available in the dining area. The home also has wine tasting evenings and a regular tuck shop. Four residents and the relative confirmed that clergy visit the home regularly. One resident stated that they received communion regularly. Information about residents’ religious preferences and cultural aspiration were seen on file. The relatives spoken with feel the clients are well cared for and that they are made very welcome and part of the home. The inspector observed that the relatives visiting that day had been offered refreshments. There were cold drinks available all day in the communal areas, hot drinks, biscuits and cake was taken around regularly. All the residents stated that the day routine is flexible and a meal can be put aside should they wish. The inspector was able to speak with the chef. There were good systems in place for cleaning and the home is in the process of implementing hazards and risk assessments. The menus are kept in the kitchen and in the dining room on each table. Individuals’ likes, dislikes and special diets were recorded and the chef was aware of individuals’ preferences. The inspector viewed the four-week menu and found it to be variable and balanced. The residents are given a choice or alternative meal if they do not like the meal for that day. The managers and chef have developed a pilot menu offering two choices to residents making the range of choice and variation greater. This was done following wishes expressed by residents. Records seen showed that alternatives were made available and food provided at each meal is recorded. The residents and relatives felt the food was fine and of good quality. The residents were very happy with mealtime experiences and felt they were not rushed. Three residents stated that the food was good and personal favourites were made available. The meal was observed by the inspector and found to be relaxed, unhurried and the food attractively presented. Daily records of foods served and temperatures of hot probed meals and freezers and fridges are kept by the cooks and found to be satisfactory. Environmental Health Officer has not visited the home for some time. Westlands House DS0000012233.V310612.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues that protects residents from potential abuse. EVIDENCE: The residents and relatives spoken with stated that they would go straight to the manager or senior carer if they had a concern or complaint. They confirmed that the staff are good and listen to their concerns. The relatives felt that the staff were patient, caring and willing to listen. The inspector observed this throughout the day. The residents and staff spoken with were aware of the home’s complaint procedure. A copy of the complaints procedure is available in each bedroom in the home’s service user guide. A comments box is kept in reception. The home’s complaint procedure includes the address for the Commission and that all complaints will be dealt within 28 days. A copy of the home’s complaint procedure is displayed in reception. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 16 The home has received two complaints in the last twelve months. The complaint log was seen and showed that both complaints had been promptly resolved and detailed records were available in the individual resident’s file. All the residents spoken with stated that they always felt safe at the home and the relatives also confirmed this. The staff spoken with confirmed that they have received instruction and are aware of the protection of vulnerable adults from abuse. They have had training on recognising and reporting of concerns or suspicions. The staff spoken with were clear about their responsibilities regarding protection of vulnerable adults. The managers confirmed that all staff undertake instruction in adult protection and abuse on induction and refresh their understanding by attending specific training on abuse. There has been no allegation of abuse at this home since the last inspection. The home has a copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure from 2003 and it’s own policy and procedures reflecting the guidelines from Hampshire County council’s own policy. The managers were advised to ensure they have an up date copy. All the staff spoken with stated that there was an open and encouraging ethos to speaking up when things are not quiet right and issues being dealt with promptly. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a clean, homely, comfortable and suitable environment for the residents. The décor within the home is of a high standard with evidence of on-going maintenance; improvements and satisfactory infection control practices. EVIDENCE: The residents stated that the home is clean, warm and no offensive odours were detected. They also confirmed that there has been on going decorating. The inspector observed this on the tour of the home. Since the last inspection, a large extension has been added to the home in keeping with the style of the original house. The home has increased its numbers of residents from 17 to 33. A new conservatory has been added and an external corridor has been internalised. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 18 The manger confirmed that there is on going redecorating and refurbishment throughout the home keeping the home looking fresh and well maintained. The maintenance records confirmed this. The home employs a full time maintenance man. There is a large mature south facing garden with various seating areas under trees. All the residents spoken with liked their bedrooms. The home’s radiators and pipe work are in the process of being made safe in the existing part of the house, ensuring that potential hot surfaces are kept to low temperature. The new build has under floor heating. A random selection of the bedrooms where seen on a tour around the home and were found to be clean, bright and warm, furnished to the individuals taste and personalised. Four residents’ spoken with felt there were enough toilets and bathrooms. There is a platform lift and stair chair lift giving level access to the first floor. During the tour of the home, the inspector noted that all communal hand sinks had liquid soap for washing hands with terry hand towels that are changed regularly throughout the day by staff to reduce the potential for spread of infection. The managers confirmed that they have a delicate disposal system that is severely damaged if paper towels are accidentally flashed down the toilet. Other methods of drying hand that promoted good hand hygiene were discussed. There were gloves and plastic aprons available in different places around the home, including the laundry, toilets and bathrooms. The residents and relatives stated that the staff do use them and the inspector observed this during the visit. The staff confirmed that they have received regular training on infection control. The managers confirmed that night staff do most of the laundry duties. There is an industrial size washing machine and a separate tumble dryer. Three residents spoken with stated that they were happy with the laundry service provided. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff at the home are well trained, supported and employed in sufficient numbers to meet the residents needs. There are satisfactory recruitment procedures that ensure residents are not put at risk. EVIDENCE: The residents spoken with described the staff as ‘caring, friendly, helpful and around when you need them.’ All residents spoken with stated that the staff were always polite and approachable. Twenty of the residents spoken with stated that they were happy at the home. All the residents and relatives spoken with said there was sufficient staff around and that the staff know what they are doing. The staff rotas seen for the last week in August and first week in September 2006 show that there are a minimum of four staff on duty each day and three waking night staff on each night. The managers, administrator and activities co-ordinator are not included in these figures. The rota shows a mix of experience and new staff and the managers confirmed that all staff are over eighteen years of age. The home also employs separate ancillary staff for cleaning, kitchen and maintenance. There is an administrator employed by the home. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 20 The staff spoken with felt there was a good skill mix within the staff team and they worked well together as a team. The staff asked had received a copy of the General Social Care Council’s code of practice and extra codes were available in the office. A copy was also available on each staff file. The managers confirmed that they are working towards achieving 100 percent of carers with qualifications in care. 86 of home’s carers hold a qualification in care. Out of the fourteen carers employed by the home three hold or in the process of completing a National Vocational Qualification (NVQ) level two in care and two NVQ level three in care. There are a further seven overseas carers who hold equivalent to NVQ level three in care qualifications in their respective countries. The staff spoken with felt that the recruitment process within the home is thorough. The inspector was able to see four different staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. Other records seen on file include signed contract of employment, job descriptions, criminal record bureau and protection of vulnerable adults register checks. The manager explained that the assistant manager is responsible for identifying training needs and securing training for the staff. The records of training were seen and found to be detailed. These included copies of certificates. The staff spoken with stated that the induction programme run by the home was useful and detailed. The files seen held records of the individual staff Skills for Care induction training covering the key areas with the signatures of the staff member and trainer that meets the recently amended Skill For Care standards for induction. The home’s training records shows that external and internal training is done. The staff confirmed that they undertake training regularly and the inspector viewed copies of individual staff training certificates and other records of instructions. The staff have received training in the necessary health and safety subjects such as fire safety, first aid, moving and handling, health and safety, food hygiene, infection control and risk assessments. Other training courses attended by staff include abuse, dementia, dealing with challenging behaviour, and safe administration and handling of medicines. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 21 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run well by an experienced owner manager. There is a good system for involving residents in the day-to-day running of the home and an appropriate, fully auditable quality assurance system. The home does not support residents with their financial affairs. The residents’ health, safety and welfare are well promoted by the home with systems that ensure everyone is protected within the home, although fire safety door are not to be wedged. EVIDENCE: The owner manager is in the process of promoting the assistant manager as the registered manager for the service. The owner has many years experience in running a business and managing a care home. She holds National Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 22 Vocational Qualification (NVQ) level 4 in care and registered manager’s award. The assistant manager has over six years experience of management within residential care and holds an NVQ level 3 in Care, she is in the process of completing her NVQ level 4 registered manager’s award. The residents and staff spoken with confirmed that there is a clear line of authority within the home. The home has a positive supportive ethos with a programme of one to one monthly supervisions, annual appraisals and various resident and staff meetings that are minuted. These records were seen on this visit and found to be satisfactory. A poster in reception advertised the forth-coming residents’ meeting. The managers confirmed that they were not appointees for any client. All the staff, residents and relatives spoken with found the management very pleasant supportive and approachable. The residents stated that their family or financial appointees rather than the home look after their money. Regular risk assessments fire safety and environment are undertaken and recorded to ensure that the safety within the home room by room. These were seen and found to be satisfactory. The managers explained the formal quality assurance process is on going throughout the year. Policies and procedures are audited annually by the home and some tasks are monitored daily, weekly, monthly, quarterly and six monthly. The records were seen by the inspector and found to be satisfactory. The staff spoken with were aware of the audit process. The owner manager undertakes monthly monitoring visits on the performance of the home and provides a written report. These reports were available in the home and copies have been sent to the commission. This was a requirement made at the previous inspection that has been met in full. The residents spoken with stated that they felt their opinions were valued within the home and many participate in the residents’ meetings. Minutes for these meetings were available. The staff felt they were included in the day-today decision making within the home, stating that changes and or issues are discussed and actions agreed at regular staff meetings that are minuted. The minutes were available from the offices for reference. The managers shared with the inspector the quality survey questionnaires completed by residents, relatives, friends and health and social care professionals. These were found to be positive with issues identified followed through and resolved promptly. All the residents and relatives spoken with stated that they felt safe at the home and two confirmed that the fire alarms are regularly tested. The managers explained the recording system for fires safety maintenance, training, evacuation and visual checks completed by the maintenance man. Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 23 The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals to ensure the safety of the residents. However, it was noted that fire alarm test were being carried out monthly. This was discussed with the managers who stated they had been advised of this in the past by a fire safety officer but would immediately start testing the fire alarm weekly. It was noted on the tour of the home that the bedroom fire doors were being wedged open presenting a fire safety hazard. This was discussed with the managers who agreed that all wedges would be removed in the interim until an automated release system linked to the fire alarm could be installed. The home has basic information on the Control of Substances Hazardous to Health (COSHH) and was advised to acquire information leaflets (Data Sheets) for each chemical being utilised within the home. Westlands House DS0000012233.V310612.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 3 X X X X X X 3 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 X 3 X 3 X X 2 Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 25 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 OP38 Regulation 13(4)(a)(c) 23(4)(a) Requirement The provider must ensure that all fire safety doors are kept closed at all times unless they are secured open with an automatic release system that is directly linked to the home’s fire alarm. Timescale for action 30/09/06 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 Standard Good Practice Recommendations Westlands House DS0000012233.V310612.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000012233.V310612.R01.S.doc Version 5.2 Page 27 - 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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