Inspection on 20/10/08 for Westlea

This inspection was carried out on 20th October 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westlea 01/06/07

Westlea 20/04/06

Westlea 06/12/05

Westlea 17/02/05

Westlea 19/10/04

Westlea 18/03/04

Westlea 17/11/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Westlea 121 High Street Leagrave Luton Bedfordshire LU4 9JZ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Andrea James     Date: 2 0 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Westlea 121 High Street Leagrave Luton Bedfordshire LU4 9JZ 01582574587 01582847232 p.pugh@Luton.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Patricia Pugh Type of registration: Number of places registered: Luton Borough Council care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Westlea is a large Luton Borough Council residential care home that provides permanent and respite care to people . The homes location is on the main street in Leagrave providing easy access to local amenities. The main advantage of the location was the vicinity of the Leagrave medical centre. Thus, the home had various medical professionals visiting on a regular basis and providing a fast response to any health emergencies. The home provides a comfortable and homely atmosphere in a safe and domestic style environment. The accommodation includes single occupancy bedrooms, several lounges/ dining areas, bathrooms and toilets were strategically placed within the home. The home had seperate smoking room and visiting areas,a hairdressing room and two shaft lifts providing access to both floors. Parking facilities for several cars were available. Care Homes for Older People Page 4 of 30 Over 65 34 0 Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is a 1 star.This means that people who use the service experience an adequate quality outcome. This was an unannounced key inspection undertaken on the 18th of August 2008. The manager was present for the duration of the inspection process which lasted for 6.5 hours. The report consists of information received from the manager, several relatives, care staff , auxillary staff, people who use the service and the Annual Quality assurance Assessment ( AQAA) tool which was received from the home. Several surveys completed by people who use the service and the care staff were also used as evidence Care Homes for Older People Page 6 of 30 to form the contents of this report. The report followed a case tracking methodology where a sample of people were selected at random to see what is was like for them living at the home. These peoples care plans were inspected and where possible they, their key staff and relatives were spoken to. What the care home does well: What has improved since the last inspection? What they could do better: The home should ensure that medication procedures for storage and administration is reviewed and changed to reflect good practice and safeguard people who use the service. There is also a need to ensure health and safety within the home is maintained at all Care Homes for Older People Page 8 of 30 times so that people are free from avoidable hazards in regards to the environment and fire. Arrangements should also be made to ensure all staff have satisfactory training in place to be able to provide effective standards of care to people at all times. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good systems were in place to ensure people receive enough information about the services the home offers, as a result peoples needs were met. Evidence: The home provided up to date information about its facilities and services in a suitable format. These were supported by the needs assessments to enable prospective people to make decisions about the admission to the home. The recent review of the Service User Guide was undertaken by the support of two of the people currently using the service. The homes Statement of Purpose and Service User Guide had been reviewed and they were available and displayed in a suitable format for prospective residents to make an informed choice about whether or not to use the service, both contained the necessary information required. People spoken to as part of the inspection process supported this Care Homes for Older People Page 11 of 30 Evidence: evidence.The homes last inspection report was displayed and available within the home. Further information was provided in the form of the minutes of the last residents meeting and displayed on the reception notice board in a suitable userfriendly large print format. Evidence examined confirmed that the residents whose lives were tracked had written contracts with the home, they were provided with a statement of terms and conditions at the point of moving into the home: this included the fee details. the contracts examined had been signed by the residents or their representatives, which authenticated and confirmed their agreement with the terms and conditions. There was evidence that the home had undertaken an assessment of the residents needs on admission and then regularly reviewed this information and updated it when those needs changed. The needs assessments helped to form the basis of the care planning process. Those records examined of the residents lives whose files were case tracked had been signed and dated by the residents which confirmed they had been consulted and their agreements sought. The service offered opportunities for people to visit the home prior to moving in. One person spoken to said i was able to spend a night here before i moved in. The home did not admit people who needed intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had satisfactory procedures in place for meeting peoples health care needs through effective care interventions, however further development was needed to ensure the medication procedures for administration and storage is reviewed, as a result people could be at risk. Evidence: A sample of the residents care plans and supporting documentations to include risk assessments were reviewed and found to contain satisfactory information to be able to meet and deliver good care. The care plan documentation had clear interventions for meeting the needs of people in regards to skincare, tissue viability, social history, religious needs and individual diagnosis etc. Interventions recorded were clear and reflective of information identified in the needs assessments. There was evidence that the residents care plans were being reviewed, we saw Care Homes for Older People Page 13 of 30 Evidence: information to suggest all the people living in the home had received a review since the beginning of 2008. Risk assessments for bathing, moving and handling, tissue viability and the prevention of falls had been completed and reviewed at suitable intervals. Residents weights had been monitored which supported other records completed by the home. Information guidance documentation and monitoring records are evident for some residents in specific health care needs such as diabetes which were closely monitored. Evidence seen supported the fact that residents were enabled by the home to access a variety of health care services to meet their assessed needs. This again was evidenced by records for dietitian and occupational health therapist visits. There were no residents who were able to self medicate at the time of this inspection. The medication records, storage and procedures were checked for those residents whose lives were being tracked as part of this inspection. All staff administering medication had recently received training. The Administration of medication to residents was observed during lunchtime on the day of the inspection. The policies and procedures for medication were review on the 14th of April 2008. The procedures for administering daily medication to include controlled drugs were inspected and most areas found to be satisfactory. Monthly audit checks were undertaken by the manager and general risk assessments were in place to safeguard people using the service. Further development was needed in some areas, to ensure that all medications stored in the home are in the original containers with the prescribers instructions. One person was prescribed Warfarin to be giving daily but although the instructions of this was on the MAR (Medication Administration Record) sheet it was not being prescribed. Staff said this was because the doses changed and they were waiting for review to be undertaken on the 24th of September 2008. For another person PRN medication was being prescribed on a daily basis from the 07/09/08 to the 17/09/08 without being reviewed. (Spirivia) tablets were also found in a container without any instructions for administration. This medication was also out of its original container and had no name to indicate who the medication belonged to. The evidence from speaking with some residents was that they were treated with respect and their rights to privacy was upheld. This was consistent with observations made during the inspection. Residents had access to a phone that was portable, enabling them to use it in the privacy of their own rooms if they so wished. One resident commented that they treat me like an adult here, the staff are very helpful Care Homes for Older People Page 14 of 30 Evidence: staff were observed to knock on residents bedroom doors, bathrooms and toilets before they entered. The home had a death and dying policy and arrangements for people upon their death was recorded in their care plan documentation. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Their lifestyle choices and dietary provisions experienced by the people using the service was very good as a result peoples needs were met. Evidence: The home provided a good standard of activities for people using the service. They employed a full-time activity coordinator, who had implemented various activities to stimulate people on a daily basis. The coordinator presented us with a weekly timetable which was also displayed in the Communal areas of the home. Records Inspected showed what activities were undertaken on a daily basis. These included quizzes, bingo, library pictures, story, music, gentle exercises and arts and crafts. They are also provisions made for weekend entertainment were various choirs were welcomed into the home to sing for the residents. There was evidence to suggest individuals and small group activities were undertaken for people in accordance with their wishes and needs. We observed one person having a manicure with the activity coordinator on the day of the inspection. Several of the residents were also escorted to have their hair groomed by the hairdressers. We were informed that people were encouraged to access Care Homes for Older People Page 16 of 30 Evidence: community activities and a group of people had recently visited Buckingham Palace and South end. One person spoken to said staff would assist her to buy personal belongings in the town centre. Some people commented that the home could be improved by having an activities room where people could go to and the work undertaken by the residents could be on display. Evidence suggested people were able to maintain regular contact with their relatives and friends without restrictions and people were supported to ensure that this happened. Residents spoken with said their relatives and visitors were able to visit them at any time and they were able to receive visitors in private. Relatives spoken to said they were always made to feel welcome. There was evidence that residents were encouraged to bring personal possessions with them into the home. Peoples bedrooms were individualised with their personal possessions. One person had been able to take her pet bird with her to the home and this pet was kept in her bedroom. Meetings facilitated by the home for the residents were held on a regular basis and the minutes were printed and displayed in large print in the Communal area of the home. Observations were made over the tea time period during the inspection where people receive their meal in a comfortable and unhurried way. Residents were observed being offered a choice of meals and beverages and those with dietary or cultural needs were being accommodated for to include diabetics. Peoples individual and nutritional needs were recorded in care plan documentations and other part of the menu planning process. The Menus examined generally offered a choice and nutritious and wholesome diets were available for people, these were displayed on a noticeboard within the home . As a result of this people were able to say what they were having for tea and could ask for an alternative if they so wished. Residents spoken to said they enjoyed the meals that were offered to them. One person said the food is great and if you dont like the choice they give you something else that you do like. Some people commented in their residents meetings that they did not like for example mashed potatoes but would prefer them boiled while others stated they would like a choice of Caribbean meals and some said they preferred mushy peas. There was evidence in the menu planning process that these needs were incorporated. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home satisfactory systems in place for dealing with complaints and safeguarding from abuse, as a result people were protected Evidence: The home received one formal complaint since the last inspection. The records seen suggested this was satisfactorily resolved and the correct procedures were followed. Records were kept of all concerns and complaints previously made and people spoken with were aware of how to complain and to whom. One person said they felt comfortable and confident complaining. The homes complaints procedure information was made available to the residents, relatives and visitors. A copy was available and displayed in the reception foyer. Information on how to complain was also included in the information provided to residents and their relatives on admission into the home. One resident commented during the inspection there are residents meetings every month, so we can voice our opinion if we werent happy, we can talk to them then.. The home had satisfactory procedures in place to safeguard residents from abuse. The majority of the staff received training in 2005 and only two had the training 2007 several staff required refresher training in the Safeguarding of Vulnerable Adults. Most care staff spoken to said they knew what to do in the event of witnessing an alleged case of abuse occurring. Since the last inspection they had been one notifiable incident in accordance with the SOVA policy and guidance, which was reported to the Care Homes for Older People Page 18 of 30 Evidence: Commission for Social Care Inspection at the time. Evidence examined supported a process that had been followed to safeguard and protect people. The homes policies and procedures regarding residents money and financial affairs were generally satisfactory and protected residents from abuse. Money held by the home for two people whose lives were case tracked was checked and balanced with the record held, the monies were stored safely and individually for each person. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environmental standards of the home was good, people were able to live in a comfortable and well maintained environment, as a result peoples needs were being met. Evidence: The home ensured that the environment was well maintained and offered people a homely and comfortable place in which to live. Communal space available within the home included areas residents could meet visitors in private and outdoor space which included a new conservatory and outdoor seating area. A dedicated smoking room for residents was also available. Various Communal furnishings throughout the home had been replaced as part of the ongoing refurbishment programmer to improve the quality of the homely environment been created. People spoken to said they were happy with the new environmental standards. On touring the environment we identified that new furnishings,flooring, doors, grab rails etc had been implemented that created a more welcoming environment. Relatives commented that they liked the home. Care Homes for Older People Page 20 of 30 Evidence: Specialist equipments were provided to ensure people were able to maximize their independence when receiving personal care or being transferred. These included various types of hoists, grab rails and assisted toilets and baths. New grab rails were being fitted on the day of the inspection to the first floor of the building. Several bedrooms were inspected during the site visit and they were all found to suit the needs of the people using the service. The decor was suitable and some decorations in places were relatively recent. A programme of regular redecoration of residents bedrooms was evident and residents were given the opportunity to personalize their bedrooms with various furnishings. The home appeared suitably clean and free from offensive orders and auxiliary staff were seen cleaning the home on the day of the visit. The home achieved a five-star rating from the environmental health inspectors in November 2007 for exceptional hygiene standards. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels and the competency of staff within the home was satisfactory, further development was needed to keep people updated. Evidence: Sufficient numbers of staff were provided to meet the needs of residents in the home. On the day of the inspection 6 staff were rostered on to work in the morning and 5 in the evening. This was also complimented by a team leader which was assigned for each shift. The manager said they had 4 vacant posts which were due to be recruited in the near future. Staff members spoken to said we could do with having more staff. This comment was also made at the last inspection. Some staff commented that they often worked short staffed. One staff said its not that the manager doesnt support us but when we book agency cover they sometimes dont turn up, so we have to work short. Other staff members spoken to felt they had sufficient staffing levels. The staff morale at the time of the visit was good and staff spoken to said they felt supported by the team leaders and the manager. One staff said we have a good team . Another said the manager is lovely. When asked what they would change about their working conditions several staff said nothing. The percentage of staff qualified at NV (National Vocational Qualification) level 2 or 3, Care Homes for Older People Page 22 of 30 Evidence: was at 67 which increased since the last inspection. This was evidenced in the training records where 20 of the 32 care staff to include team leaders had achieved the qualification. Staff records examined indicated that the homes recruitment procedures were generally satisfactory. Staff files inspected suggested satisfactory CRB (Criminal Record Bureau)clearances and references were obtained prior to the commencement of employment. Staff spoken to supported this evidence. Staff records inspected showed evidence of individual training but no specific development plans were in place for individual staff members. Staff spoken with reported various training courses which they attended. They were however some gaps in the training undertaken for staff to include a Safeguarding of Vulnerable Adults which suggested 28 care staff have not had this training since 2005. This was also the case for training in risk assessments, first aid, manual handling and infection control. Several staff had not received necessary specialist training to meet the needs of the residents. These included mental capacity, dementia,stroke, catheter care and diabetes which was necessary to meet the needs of people using the service. The manager had identified some of these needs and was in the process of accessing the training for members of the staff team. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has effective management structures in place and the interests of people using the service were safeguarded. The process for quality assurance was effective some improvements were needed in health and safety but people in general were safeguarded. Evidence: The manager and team leaders were present for the duration of the inspection process. The area manager came into the inspection at the feedback process. The manager said that she had an NVQ level 4 and 5 in management and has recently completed her Registered Managers Award (RMA). There was evidence to suggest the home was well run and people felt safe. One person said, the home is OK, Im happy here. One person said, I feel safe, another said, the manager is okay. Care Homes for Older People Page 24 of 30 Evidence: The home had made improvements to their quality assurance systems and as a result peoples views were obtained, the recommendations were analyzed and acted upon and this was evident in records inspected. This example was evident where people voiced their opinions in residents meetings that they wanted a particular meal and this was included in the menus see, (daily life and social activities section of this report). The home had set themselves 40 objectives to be achieved under ensuring quality outcomes for people and 38 of these to date had been achieved. Improvements to be achieved in the next 12 months had also been set to include widening patios and having a summer house. There was evidence that people using the service and relatives received questionnaires which were analyzed and published. This year 76.4 of relatives were happy with the home. 20 surveys received from people and 16 from staff sent to the commission suggested that peoples views were listened to and that they were happy with the service provided. Residents financial records and secure safekeeping of money and valuables were being maintained satisfactorily. The residents financial interests were safeguarded and their interests protected. Evidence examined demonstrated that staff receive supervision and appraisals in the way that they preferred, records inspected suggested this was carried out for all staff on a monthly basis for both day and night staff. The team leaders undertook this task with the manager and all spoken to were able to support this evidence. The home had satisfactory health and safety procedures. They have implemented several risk assessments for bathing, trips and falls, moving and handling and other areas identified as potential hazards to people who use the service. The fire records inspected suggested people were risk assessed on an individual basis and a red or green sticker placed on their doors to identify what level of assistance would be required in the event of a fire. This was in need of reviewing as one user had only one sticker on his door suggesting minimum assistance would be required in the event of a fire but he was a high risk and needed to have another colour sticker on his door to indicate this. The test of fire alarms and fire drills were satisfactorily maintained and were undertaken on a regular basis. Some peoples safety was compromised as we identified some doors were not able to shut on their rebate. All staff received in-house fire training in 2007 but there was no evidence that care staff had received any health and safety training in the home. We identified that in one of the small dining rooms a mop and bucket with water was left in the middle of the floor for a considerable amount of time which could be a trip Care Homes for Older People Page 25 of 30 Evidence: hazard to people using the service. We interviewed relatives in this room for more than 20 minutes where this hazard was left unattended by staff. The hygiene standards in the home was satisfactory but closer attention was needed in the kitchen where storage cupboards with several boxes of cereals were left open and as a result could be contaminated before consumption. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 9 13 (2) Staff must adhere to the 31/07/2007 homes? policies and procedures for the receipt, recording, storage, handling, administration and disposal of medicines. to ensure peoples safety are assured. 2 30 18 (1) (c) (i) Staff must receive training 31/08/2007 appropriate to the work they are to perform, including specialist training to meet the needs of the residents. Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 All medications stored in the 30/11/2008 home must be stored in their original containers or dossett boxes with the name of the person to whom the medication belongs and the prescribers instructions. To safeguard people from being given incorrect medication. 2 9 13 The procedures for administering PRN medication on a prolonged basis must be reviewed. To ensure it safeguards people using the service. 30/11/2008 3 30 18 All care staff must receive specialist training in areas such as diabetes, stroke, SOVA, catheter care etc. In order to be able to offer competent service delivery to people using the service. 30/11/2008 4 38 13 Arrangements must be made to ensure all parts of 30/11/2008 Care Homes for Older People Page 28 of 30 the home where service users have access to are free from hazards to their safety. To maintain the health and safety of people using the service. 5 38 23 Arrangements must be 30/11/2008 made to ensure adequate precautions against the risk of fire is implemented where doors are able to shut on their rebates. To protect the people using the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 30 Arrangements should be made to ensure all care staff have in place a training and development plan that identifies the training needs of the individual and the actions in place to meet the needs identified. Arrangements should be made to ensure mandatory training is up- dated for all care staff on a regular basis. The risk indicators for people in the event of a fire should be revisited. Arrangements should be made to ensure all staff receive health and safety training in the home. 2 3 4 30 38 38 Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!