Inspection on 09/01/07 for Westlands Retirement Home Ltd

This inspection was carried out on 9th January 2007.

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

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

Other inspections for this house

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Westlands Retirement Home Ltd Reed Vale Teignmouth Devon TQ14 9EH Lead Inspector Graham Thomas Unannounced Inspection 09:15 9 January 2008 th 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 Retirement Home Ltd DS0000068079.V350802.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 Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlands Retirement Home Ltd Address Reed Vale Teignmouth Devon TQ14 9EH 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) 01626 773007 Westlands Retirement Home Ltd Ashley Baron James Rayfield Elizabeth Anne Feasby Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One resident (named elsewhere) who is under the age of 65 and having a physical disability, may be accommodated 25th April 2006 (under previous registration) Date of last inspection Brief Description of the Service: Westlands is a large detached house in a quiet residential area, a little over half a mile from Teignmouth town centre. Accommodation is arranged over three levels with access provided by a shaft lift. Most of the 19 bedrooms have en suite facilities, and there are good views from some windows. There is a large, accessible sun terrace, a garden and a car parking area. The home provides 24-hour care and support to people aged sixty-five and over. Assistance is given with everyday tasks such as dressing, bathing, and general mobility. Activities and entertainment are regularly provided. Transport to appointments is provided, and also for shopping trips and regular leisure outings. Since the home was last inspected the Provider of the home has changed from a partnership to a limited company. Although this is a significant change of legal responsibilities, in practice the running of the home remains unchanged. At the time of this inspection weekly fees ranged between £337 and £545 which did not include newspapers, hairdressing or private chiropody services. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star . This means the people who use the service experience good quality outcomes. Before the inspection, the Responsible Individual completed an Annual Quality Assurance Assessment (AQAA). This a questionnaire sent by the Commission which provides information about the home. Surveys were also sent to people living in the home and their relatives. These were returned by 2 people living in the home and 3 relatives. We made an unannounced visit to the home and spent ten and a half hours there. During our visit we toured the premises, spoke individually with 7 people living in the home and others in small groups. We also spoke with three staff and the Registered Manager. A sample of care plans and staff records was examined. Other records and systems concerning the running of the home were also inspected. This included the home’s system for administering medicines. What the service does well: • • • • • • • • • • • People have enough information about the home before they make a decision about moving in People living in the home are well supported to get the medical care they need There is a safe procedure for administering medicines Staff respect people’s privacy and dignity There is a varied activities programme and annual events such as the summer garden party. Visitors to the home are always made welcome Staff listen to people’s concerns and act upon them. They know how to protect people from abuse. Westlands is clean, comfortable, homely and generally very well maintained Staff are friendly and welcoming. There is a generally safe recruitment procedure in place to protect people living in the home. The Manager is popular and respected by people living in the home, relatives and staff. There are good systems in place to preserve the health and safety of people living in the home, staff and visitors. Westlands Retirement Home Ltd DS0000068079.V350802.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. The summary of this inspection report can be made available in other formats on request. Westlands Retirement Home Ltd DS0000068079.V350802.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 Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving to Westlands receive enough information to be able to make an informed decision. They can feel confident that the home has made sure it can meet their needs before they move in. EVIDENCE: Relatives and people living in the home felt that they received enough information before moving in to make an informed decision. In a survey one person commented “My elder sister was a resident in this home. She receive excellent care in the last 2 months of her life. So therefore I knew a lot about the home and the staff who run it. To look anywhere else was out of the question” In conversation another person confirmed that, although initially reluctant to move into residential care, she had been reassured by two visits to the home Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 9 before making a final decision. Written information about the home is available for people who may wish to move in. Individual files showed that assessments took place before people moved to the home to ensure it could meet their particular needs. Assessments included, where appropriate, nursing assessments where people had been referred from hospital. Specialist equipment had been obtained for those who required it and care plans and risk assessments had been produced. Some of assessments were, however, unsigned and undated. This is important so that any queries about a person’s history can be answered accurately.. The home reserves one place for respite care. However intermediate care is not routinely provided by the home. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. People living at Westlands receive a good standard of care. However, individual plans are not sufficiently clear or well maintained. EVIDENCE: Both people living in the home who returned surveys to us stated that they always received the care and support they needed. One commented, “The staff are excellent and if you need that little extra care they are always there” In conversation, one person was keen to tell us how they had rung the call bell in the middle of the night and asked for a cup of tea which was brought straight away. Another said that the care she received “couldn’t be better” One relative felt that there was not enough attention to small details such as shoe polishing, and the cleaning of spectacles. However this person stated that Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 11 her concerns were dealt with when staff were made aware of them. On the day of our visit, people appeared to be clean well groomed otherwise cared for. Each person had an individual file containing their care plan and other information. We examined three of these and discussed care planning with the Registered Manager. The plans were set out in individual sections with a summary. In those examined, only the summary had been completed. Although this gave a reasonably detailed account of individual needs, this format made information more difficult to access. There was information in the plans about daily routines and preferences concerning food and bathing. There were also risk assessments and details of routine and specialist medical appointments. People living in the home were with whom we spoke were all satisfied that they received any medical attention they needed. During our visit, one person was supported to attend a hospital appointment. Those staff with whom we spoke were aware of individual needs and preferences. Not all the information in the plans had been kept up to date. For example, one plan stated that the person would manage their own medication. However, the summary of her needs on admission stated that the home would take over the administration of the person’s medication. This was changed immediately during our visit. It is important that these records are accurate so that there is no possibility of error. Some of the documents in the plan were unsigned and undated. This means that it would be more difficult to notice any patterns or follow up issues with the relevant person. One record contained personal details concerning a number of individuals. This is not considered good practice as it may compromise their confidentiality. None of the care plans contained photographs of the individual as required by regulation. The organisation of the plans made it difficult to follow how the person’s specific assessed needs had been addressed and reviewed. The above issues were discussed with the Registered Manager. The home’s system for administering medicines was examined. Some people managed their own medication and there were risk assessments for this in their individual plans. However, as stated above, one was found not to be up to date and was updated during our visit. Other medicines were securely stored in a locked cupboard. Refrigerated medicines were stored in a locked box in the home’s refrigerator. At the time of our visit the Registered Manager stated that there were no controlled drugs in use though she was aware of the recording and storage requirements involved. Homely remedies were in use and their use was supported by a professionally approved list. Records of the medicines administered were up to date and in good order. Accurate recording was reinforced by a system auditing system in which a second person double checked the medicines each day. We observed medicines being given and a sound procedure was used. Medicines received into the home had not been recorded on the administration record. This makes it more difficult to account for individual quantities of medication. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 12 During our visit we observed staff interacting with people living in the home. In all these interactions, staff were courteous and respectful. Those with whom we spoke said that they were always treated with respect by staff and that their privacy and dignity was preserved. Westlands Retirement Home Ltd DS0000068079.V350802.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): Standards 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. There is sufficient support for people living at Westlands to follow their individual routines and preferences. EVIDENCE: On the day of our visit, it was evident that each person had an individual routine which was understood and respected by staff. Those who preferred to rise early were seen up and about when we arrived. Others who preferred to rise later were received their breakfast accordingly. These individual preferences were set out in their individual plans and understood by the staff with whom we spoke. One relative stated “Every effort is made to personalise care and allow the individual resident to live life as close as possible to what they would wish” On the afternoon of our visit a visiting entertainer was in the home. Those people who wished to were joining in singing. People with whom we spoke during our visit said that they enjoyed the activities provided by the home. This was reflected in the surveys received from people living in the home. For example, one person stated, Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 14 “We have trips out in the minibus taking it in turns. We have quizzes especially Sunday afternoon which we all enjoy. Keeps our brains active” A relative commented that, “The Christmas party is great fun – even off duty members come in to help. The summer garden party is good too. Liz goes to town with Christmas decorations – they really try to make Christmas special” However there was one comment that the scope of some activities was limited. This person felt that activities should “… include classical music and quizzes that do not patronise. Also games other than bingo and beetle drives – a bit more variety” All the people with whom we spoke stated that their visitors were made welcome and that refreshments were offered when they arrived. Most people who returned surveys stated that they were always kept up to date with important issues concerning their relative or friend living in the home. People living at Westlands who returned surveys stated that they always liked the meals. Those with whom we spoke were similarly positive. One person commented “Being a diabetic I have to have special meals at times and they always cater for me” However one visitor reported that her relative sometimes found the food “monotonous” and felt that the alternatives on offer could be improved. However, it was clear that this was not the view of the majority and there was evidence that the service works hard to meet individual tastes and needs. On the day of our visit the main meal consisted of roast chicken with stuffing, roast potatoes and three fresh vegetables, which we saw being prepared. There was a trifle to follow. We joined people living in the home and sampled this meal which was generally eaten with relish. The home’s dining room had been attractively laid out and individuals helped to lay the table and clear away after the meal. The atmosphere during the meal was relaxed and convivial. A home-made quiche had been prepared for tea along with cakes. The menu was displayed on a blackboard and people with whom we spoke confirmed that they could request alternatives. Individual dietary preferences and needs were set out in care plans. One person required soft food and this was presented in a softened form in separate portions so that the person could experience separate tastes, colours and aromas. Alternatives were also available to meet the particular needs of people with diabetes. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Westlands, their relatives and friends can feel confident that any concerns will be listened to and acted upon. Appropriately robust procedures are in place to protect people from abuse EVIDENCE: Westlands has a clear complaints procedure and records of individual complaints and concerns were seen in our visit. In surveys returned to us people living in the home and their relatives stated that the home always responded appropriately to concerns. All but one relative knew how to make a complaint. One person had raised some issues with the Registered Manager and was satisfied that she had acted appropriately. Regular meetings are held between staff and people living in the home in which ideas and concerns can be aired. Minutes of these minutes were seen. Staff had received training in the protection of vulnerable people from abuse. Those with whom we spoke were aware of those to whom they should speak if they witnessed or suspected abuse. The Registered Manager and staff confirmed that they had no involvement in the personal financial arrangements of individuals which are dealt with by relatives or advocates if necessary. Westlands Retirement Home Ltd DS0000068079.V350802.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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Westlands live in a pleasantly comfortable, clean, safe and homely environment. EVIDENCE: Westlands is a large detached house in a quiet residential area, a little over half a mile from Teignmouth town centre. Accommodation is arranged over three levels with access provided by a shaft lift. Most of the 19 bedrooms have en suite facilities, and there are good views from some windows. There is a large, accessible sun terrace, a garden and a car parking area. One room looks directly onto a blank wall. This is used for respite care rather than permanent occupancy. Two people living in the home have access to areas of garden which they take an interest in maintaining. A shed has been provided for this purpose. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 17 The Annual Quality Assurance Assessment returned to us by the Registered Provider before the inspection stated. “We have put in a new bathroom (wet room), we have replaced the flooring right through the kitchen and staff areas, we are currently replacing all the carpets right through the public areas, we have provided ramps for better outside access and we have continued to replace the old windows.” These improvements were confirmed in our tour of the premises. The home was generally very well maintained and decorated to a high standard. However, covering on the grab rail in one en suite shower was stripping away and the door to this room would not close properly. These issues were discussed with the Registered Manager. Records were seen indicating an effective maintenance routine. These included, for example, hoist and lift servicing records and labels of testing on personal electrical appliances. Furnishing and décor in the communal areas and individual rooms were homely and comfortable. On inspection, all areas of the home were sufficiently clean and free from offensive odours. We discussed a slight odour in one room with the Registered Manager. The home’s laundry is sited on the lower ground floor. This had cleanable walls, washable floors and hand washing facilities. Washing facilities included a machine with built-in sluicing facilities. A tumble dryer is located in a separate room accessed from the outside of the building. Westlands Retirement Home Ltd DS0000068079.V350802.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): Standards 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. There are sufficient numbers of skilled and experienced staff to meet people’s immediate needs. People living in the home can feel confident that the Registered Manager is taking steps to address issues arising from a temporary staff shortage. EVIDENCE: Many positive comments were received about staff from people living in the home and their visitors. Examples included, “All the staff I have met are considerate, kind and helpful” “There is a lot of good humour and good will among the staff…” “I really think the staff are charming. My mother, although elderly and frail is very ‘with it’. She compliments them all the time – and I have never observed anything uncaring.” One visitor felt that there was a high proportion of staff whose grasp of English was not sufficient and that this could reduce the quality of the service provided. The numbers of staff were also commented upon by one relative who stated, Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 19 “…Possibly more staff should be employed for preparing meals so that the care staff are not so stretched…” During our visit the Registered Manager stated that the home was seeking to recruit care staff. A temporary shortage of staff had arisen due to a number of staff coincidentally incurring injuries outside work. One of these staff members was seen wearing splint during our visit. This was said to be the reason that the Registered Manager was spending a higher than usual proportion of her time in providing direct care to people living in the home. A sample of staff files was examined. Recruitment procedures included a formal application process, criminal records checks and references. Work permits were seen in the files of staff from abroad. Where criminal records had checks been delayed, appropriate immediate checks had been undertaken. We discussed with the registered Manager the need to record the person supervising a staff member who had commenced their duties under these circumstances. The files contained evidence of training completed and planned. Induction training had been provided to new staff who felt it was sufficient. However this training did not meet nationally recognised standards. There was evidence of other training relevant to the needs of the people living in the home. Examples included training about the care of people with dementia and those who had suffered strokes. There was also evidence of training concerning heath and safety matters such as food hygiene, infection control and first aid. One quarter of staff involved in direct care had achieved a National Vocational Qualification at level 2 or above. Other staff were completing or due to undertake these courses. Westlands Retirement Home Ltd DS0000068079.V350802.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): Standards 31, 33, 35, 36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westlands is generally well managed for the benefit of people living there. EVIDENCE: Since the last key inspection, the Ownership of the home has passed to a Limited Company. However owners of the company are the previous Registered Providers and there have been no changes to the management of the home. The Registered Manager has many years experience of working in care and has managed Westlands for eight years. She holds National Vocational Qualifications at level 4 in care and management. Comments received from relatives and people living in the home indicated that she is highly regarded. For example, Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 21 “Liz, the manager, is excellent and has high standards.” Our examination of management issues showed that there were various systems for assuring the quality of the service provided. For example, feedback was received from people living in the home and staff through regular meetings. There was an open complaints and compliments procedure. As mentioned above, a relative stated that she was satisfied that her concerns were dealt with. Issues such as staffing shortages were being addressed. The home’s environment and facilities had been improved and upgraded since the last inspection. Although the existing systems for quality assurance were effective, a systematic cycle of audit, planning and action was not evident and this is identified as a potential area for improvement. The Registered Manager and staff confirmed that they have no direct involvement in peoples’ individual finances where they are unable to manage them independently. Bills for such items as hairdressing and other small items of expenditure are recorded and the person managing the individual’s finances is then invoiced. Staff with whom we spoke felt that they were well supported by the Manager and there were regular group meetings. However there was no regular system of individual staff supervision in place. This is important as it affords individual staff the opportunity to express concerns about their work, give and receive feedback from the manager and identify any training needs. Health and safety issues were examined. The Registered Manager stated that there was an individual fire evacuation plan and that the home complied with the requirements of the fire authority. Evidence of staff training was seen in health and safety topics such as food hygiene, moving and handling and infection control. A list of qualified first aiders was seen during the visit. Staff had received specific training in the use of an aid used by one person. Measures were in place to control the potential spread of infection or toxic conditions. Staff were seen wearing aprons and gloves for cleaning and personal care tasks. The cook kept small samples of all the food eaten so that the source of any outbreak of food poisoning could be rapidly identified. Antibacterial hand gel was available for staff use. A contract was seen for the removal of controlled waste from the home. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 22 Maintenance records showed recent maintenance had taken place to equipment and services such as electrical appliances, the shaft lift and mobile hoists. Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 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 2 X 3 Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 17 Requirement The Registered Person must keep all the records specified in schedule 2 of the Care Homes Regulations 2001. In particular a photograph of each person using the service must be held. Timescale for action 15/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP3 OP7 OP7 OP3 OP7 OP7 OP12 Good Practice Recommendations Care planning and assessment documents should be signed and dated Information held in care plans should be kept up to date. The assessment and care planning process should show a clear cycle of assessment, planning action and review. Records should be reorganised so that personal details of more than one person are not held in a single record The variety of activities provided for people living in the home should be reviewed to ensure it meets everyone’s needs and expectations The grab rail in the en suite shower of room 14 should be repaired. The door to this facility should be rendered DS0000068079.V350802.R01.S.doc Version 5.2 Page 25 OP19 Westlands Retirement Home Ltd 7. 8. 9. OP29 OP33 OP36 capable of closing. A record should be maintained of the person supervising any new staff member who commences work at the home before a criminal records check is completed A more systematic planning process should be developed for assuring the continuing quality of the service A system of individual staff supervision should be developed and implemented Westlands Retirement Home Ltd DS0000068079.V350802.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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