Inspection on 03/03/08 for Westleas

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Adequate 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

Westleas 12/01/09

Westleas 18/07/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Westleas 47 Earls Avenue Folkestone Kent CT20 2HB Lead Inspector Mary Cochrane Unannounced Inspection 10:00 3 March 2008 rd 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 Westleas DS0000066037.V359536.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. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleas Address 47 Earls Avenue Folkestone Kent CT20 2HB 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) 01303 242784 Kestrel Care Limited Sita Bhadye Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August ’06 Brief Description of the Service: Westleas is a large premises offering accommodation over three floors for up to 20 residents over the age of 65, requiring residential care. The home is situated in an avenue, close to the Leas area of Folkestone. There is a mainline railway station and local bus routes nearby. There are 16 single and 2-shared bedrooms available. 4 of the bedrooms have en-suite facilities and all have a wash hand basin and a call bell system. Residents are encouraged to bring personal possessions to furnish their bedroom. There is a stair lift and a new shaft lift has just been installed to provide access to all upper floors. Communal areas comprise of a main lounge, and dining room. The home has a statement of purpose that gives information about their service. A copy is kept in each of the bedrooms. Currently the scale of fees ranges from £312.00 to £500 per week. Hairdressing, Taxis chiropody, newspapers and toiletries are at an additional charge. The most recent CSCI report is available on request from the home. Westleas DS0000066037.V359536.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 1 star. This means the people who use this service experience adequate quality outcomes. This visit to the service was an unannounced “Key Inspection” which took place over one day. All the core standards were looked at during the visit. This visit forms part of the key inspection. The registered manager and deputy manager were both available to assist during the site visit. The people living at the home and the staff on duty were helpful and cooperative throughout. The following methods of inspection and information gathering were used: At the time of the site visit there was one-to-one discussion with people who use the service, care staff and management. Staff interactions with residents, care interventions and activities were observed. Individual support plans risk assessments were looked at and discussed. Selected policies, medication charts, training matrix and training programmes and financial arrangements were looked at. A partial tour of the building was undertaken. Information received from the home since the last inspection was used in the report. At the time of the site visit the home had not received an annual service assurance assessment (AQAA) from the commission. We also looked at information sent to us about concerns and complaints and how these have been managed. We also took into account the things that have happened in the service, these are called ‘notifications’ and are a legal requirement. In April 2007 a safeguarding adults alert was raised at the home. The local adult protection team investigated this and the alert was closed. Prior to the visit surveys were sent to residents, families, and care managers. The comments on the surveys returned to us were all positive. One relative commented the home provides a friendly, family atmosphere. A resident said ‘ I am very happy here. They are very nice people” Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 6 A person who visits the home regularly said ‘they do everything they can. The staff are always friendly and I always get a cup of tea. ‘ What the service does well: People who wish to stay at the home have access to information, which tells them about the service and the care they will receive if they decide to spend time at the home. The staff make sure that peoples needs have been fully assessed before they come to stay. This will ensure that the service can give them the support and care they need. The home provides a friendly, homely atmosphere. The people living there appear relaxed and content in their environment. Residents said the staff are very kind and patient. Interactions between the staff and residents were seen to be positive and good. Residents confirmed they feel their privacy and dignity is respected. The menu provides residents with a choice of appetising and nutritious meals, which people said they enjoy. One person said ‘ the meals are good and there is plenty. They will try and get you whatever you want.’ Family and friends are welcome at the home and are encouraged to be involved in the care of their relatives. The personal care needs of the residents are met Visiting professionals said the staff contact them promptly if they have any concerns about the welfare of any of the residents. They said they have a good relationship with the home. The service has informed the commission that the registered manager will be away from the home for a period of up to 6 months commencing the middle of March. In her absence the deputy manager will be taking the day-to-day running of the home. The service did tell us the registered provider would support her during this time. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 7 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. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 People who use the service experience good outcomes in this area. Prospective residents have the information they need to make an informed choice about living in the home; their needs are assessed; and they will only be admitted if the home is confident of meeting these needs. Resident’s places are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide contains all the necessary information to assist residents and their representatives to make an informed decision as to whether the home is suitable and able to meet their needs. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 10 A copy of the statement of purpose and service users guide is kept in each bedroom. These are kept up to date to reflect the present situation in the home. The service users guide is well written. It includes information on how to make a complaint. The guide would benefit from larger print to make it easier to read for some residents. Everyone who uses the service has a terms and conditions/contract in place. This explains what the service provides for the money paid. The terms and conditions/contracts are kept in the individual rooms of the residents. They are signed by the person receiving care or their representative and the manager of the home. The home has recently reviewed there assessment procedures. The files of two most recent admissions were looked at. The service has developed an assessment format which looks at the person as a whole. It identifies the persons care needs and also looks at all aspects of their lifes. It gives a information about their past, their likes and dislikes. Pastimes and religious and cultural preferences. The home also uses the assessment undertaken by the care management team. All this information is brought together to make a decision as to whether or not the home will be able to look after the person. The home does have an interim contract with the local social cervices department to provide three intermediate beds. This is only until the end of March ‘08 when the local social services will have their own facility to provide this service. The intermediate care team assess the prospective resident and forward the information to the home. The home will make a decision as to whether or not they can offer the necessary care. The intermediate care team then provide all the additional support. Specialist services from relevant professions including physiotherapists and occupational therapists are provided to meet the assessed need of those residents admitted. One person said ’I have only been here a few days but I’m getting back on my feet again’. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use the service experience adequate outcomes in this area. Residents cannot be sure that all their needs will be met and that all risks are minimised. Action needs to be taken to ensure that the homes medication policies and procedures fully protect the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the visit the deputy manager home was in the process of transferring the care plans of the residents onto a new format. 2 plans had been started and these were looked at. 2 of the other plans were also seen. The new plans are more person centred and look at all aspects of support and Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 12 care needed by the residents. They are easy to follow and focussed on what people could do for themselves. The areas were care and support was needed gave clear and precise guidance to staff. The plans are not yet completed and did not yet identify the area of risk and what action is needed to keep risks to a minimum while allowing residents to be as independent and as possible. The plans gave good guidance on how to deliver personal care. However others were not up-dated to reflect the changing needs of the people living at the home. There are some risk assessments in place but these need to be further developed more individualised to ensure that all risks have been identified and kept to a minimum. There was evidence to show not all of the health care needs of the residents are being monitored and met. Risk assessments are not in place to give the staff the information they need to identify risk areas and what action they should take to keep health risks to a minimum. One example was diabetes. There was no plan in place as to how this was being monitored and there was no risk assessment to give the information on how to identify the complications of diabetes and what to do if these where identified. There was also no guidance in place about catheters or for people with swallowing difficulties. Daily records are kept but they do not give a clear picture about how residents spent their time and do not relate to the individual care plans. Each resident is registered with a local G.P. and any area of concern related to health is referred to the G.P. All residents receive an annual health review. The home now has regular contact with the intermediate and district nursing team and good relationships have developed. The residents have regular appointments with opticians, a chiropodist and dentists. Visiting professional reported the home always contact them promptly if they any concerns about a residents. They also staff listened to what they said and carried out specialist instructions to meet the needs of the residents. A medication round was observed during the visit. Medication was stored and dispensed safely and all medication administered was signed for. The home now has a list of staff signatures in place so it is easy to identify who has administered the medication. There are also pictures of the residents in front of the prescription. This will make sure that the right person receives the correct medication. These were recommendations at the last inspection and have now been met. Staff competencies in administering medication are checked on a regular basis. One person said ‘I always get my tablets on time’. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 13 It was seen that some medications had been hand written on the dispensing sheets. It needs to be ensured that all hand written entries are dated and signed by 2 people. At the time of the visit we were informed that a resident was self-medicating. There was no risk assessment in place and there was no assessment available to evidence how this decision had been made. Also there was no evidence available to show that regular checks were being done to ensure that the medication was being taken as prescribed. Some of the people staying at the home are prescribed medication (this includes topical creams) on a ‘when required’ basis. It is recommended that medication prescribed ‘when required’ needs have written instructions and guidance for staff to ensure that the medication is administered consistently and effects be monitored. This needs to be documented in residents care plans. It also needs to be ensured the effect of analgesia for pain is monitored. It was seen that prescribed topical are being left in on peoples bedside tables and in bathroom cabinets. Topical creams need to be stored safely. Through observation and from talking to the residents and staff there was evidence to show that privacy and dignity is up-held. Residents are well dressed in clothing appropriate for the season and appeared well kept. Staff were observed assisting the residents in a caring and supportive manner and were seen treating them with respect and understanding. Some members of staff were observed demonstrating good body language and communication skills when interacting with the residents. Members of staff spoken to confirmed an understanding and commitment to caring for older people. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use the service experience good outcomes in this area The home does provide the residents with some opportunities and facilities that enable them to maintain an appropriate and fulfilling lifestyle in and outside the home. Family links are encouraged and maintained wherever possible. The home provides nutritious and varied meals for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does provide some activities for residents and these normally happen in the afternoons. These include various board games, bingo, arts and crafts. On occasions staff do take residents out. The service does document if residents participated in activities. But this is done by just using a code letter for various activities provided. It does not state if the person enjoyed the activity or not, whether they fully participated or whether they got fed up. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 15 Other coded records indicted that people spent long periods of time lying on their beds or were asleep. They did not say whether or not the person was asked if they would like to do something and if they where supported and encourage to take part. Staff need to make sure that they document what activities the residents do on daily basis. At the moment records relating to how people spend their time are sparse. One person said ‘I like painting but would like to go out more. It depends on how many staff are about’. Relatives said they are made to feel welcome at the home at all reasonable times and no restrictions are imposed. Residents are able to receive their visitors in the privacy of their own rooms or in the communal areas. The people at the home felt that they are able to have some choice in regards to their day-to-day lives. Examples given were that they could get up and go to bed when they liked. They could choose what to eat and where to eat their meals. Generally they felt happy with the choices they are offered. All residents are invited to attend residents meetings, which are held at regular intervals. The meetings give people the opportunity to express their views and make suggestions regarding their care at Westleas and also to make any suggestions on how the service can be improved in any way. The manager told us that suggestions are listened to and acted on. The service has recently employed a new cook who is working 6 days a week. He has the necessary qualifications and training to undertake the role. Another cook works the 7th day. The menu is planned over a 4-week period. A cooked meal is provided at lunchtime. The care staff prepare the food in the evening and the training matrix indicted that staff have received food and hygiene training. Because care staff prepare the evening meal at times this leaves only 1 staff caring for the residents. The registered manager told us she will review this situation. The home provides a varied menu ensuring the residents receive a nutritious and balanced diet. Special diets are catered for. The staff keep a record of meals eaten and who has chosen what. If any dietary concerns have been highlighted about any individual then in detailed intake records are maintained and G.P’s consulted. A lunchtime meal was observed; this was relaxed and unhurried with residents able to take their time to enjoy the food. Staff were observed assisting residents to eat in a respectful way. Residents said that the food was very good and there was always plenty. They said they could have drinks or snacks whenever they wanted. A resident said ‘the meals are very nice. I am healthy’. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 16 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): 16 and 17 People who use the service experience good outcomes in this area. The people who use the service can be sure that their complaints will be dealt with. The staff have the skills and knowledge to keep residents as safe as possible. People are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in prominent places throughout the home. A copy of this procedure is also contained in the information folder available in all bedrooms. The service has systems in place to ensure residents or their representatives can raise any concerns about the service they receive. Residents indicated that they could speak to the staff if they had any concerns. Westleas has received some complaints since the last inspection. These were clearly documentation, with response to complainants, and the outcomes of complaints. All concerns and complaints are taken seriously, and dealt with appropriately. The registered manager needs to ensure that individual complaints are logged separately in line with data protection. The manager and staff told us they use complaints as an opportunity to do things more Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 17 effectively, and action is taken to prevent similar occurrences from happening in the future. In April 2007 a safeguarding adults alert was raised at the home. The local adult protection team investigated this according to their policies and procedures. The registered manager informed us the alert has now been closed. Staff are aware of what constitutes abuse and reported that they would have no problem whistle blowing if the need arose. The service told us that all staff have received training in safeguarding adults and are going to have training with regards the Mental Capacity Act. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25 and 26. People who use the service experience adequate outcomes in this area The service needs to continue to improve and maintain the environment to provide people with a comfortable homely and safe place to live. On the whole the residents benefit from a clean and homely environment This judgement has been made using available evidence including a visit to this service. EVIDENCE: Accommodation for the residents is spread over 3 floors. The service has recently installed a new lift to access all the floors and this will be up working imminently. Residents can also access the their rooms via a stair lift. The owner said that since they bought the property just over 2 years ago they Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 19 have improved the environment considerably. A partial tour of the building was undertaken. There is a lounge and a dining room and a pleasant garden for people to use in the better weather. The property is maintained to reasonable standard but there are areas that need attention. Areas of the home would benefit from redecoration and renewal. The dining room and downstairs bathroom were cluttered and in need of organising and tidying up. The bathrooms on the first and second floor are past there best and in need of up grading. It was identified that a mobile hoist could not be used in the bathrooms. This means if a resident’s conditions deteriorate so they need a mobile hoist for transfer they would not be able to have a bath. The service needs consider they are going to manage this issue. At the moment people have their own bedroom. Each of the rooms has a sink and a call bell. Bedrooms are personalised and reflect the interests and lifestyles of individuals. Radiator covers are now in place in all rooms. The service does need to develop a planned maintenance and renewal programme for the ongoing up- keep and improvements within the home. The owner /manager is aware of the work that needs to be done. On the day of the visit the home was clean and free from any offensive odours. There are the facilities available in all the appropriate areas for hand washing and the home has the appropriate facilities for the disposal of clinical waste. The service has recently up –graded the laundry area and this has been done to good standard. The home has an industrial washing with sluicing facilities. Residents said that the laundry service was very good and they had no complaints. The service needs to ensure that soiled laundry is transported correctly. The registered manager informed us that she in the process of acquiring red alginate bags for transporting and washing laundry. An infection control policy and procedures are in place and staff training is provided. Visiting professionals said ‘The decoration could improve’. A resident stated ‘The home are making improvements and investing in the future’. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use the service experience adequate outcomes in this area The staff have a good understanding of the service users and positive relationships have been formed. The residents cannot be sure that there will sufficient numbers of staff on duty at all times to meet all their needs. Recruitment policies and procedures need to be adhered to ensure the residents are fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager did inform us they are trying to recruit more staff. On the day of the visit there was 2 care staff on duty the deputy manager and the manager. The service told us they usually have and extra member of staff working from 8am till 11am but the duty rota showed that this did not happen on a regular basis because of staff shortages and difficulties in recruiting. The duty rota did include the staff position and the hours of the shifts. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 21 In the afternoon there is usually only 2 members of staff on duty for 16 residents. The service told us that usually one staff member prepares the evening meal. This means that residents could be without access to staff when they need them and potentially at risk. The registered manager needs to ensure that there is enough staff on duty at all times to meet the needs of all the residents. Staff said the amount of training available has increased over the past few months and they were able to demonstrate their knowledge on different aspects of care. The service employs 12 care staff. 6 staff have achieved NVQ level 2 or above and 2 more are about to start the course. There are some gaps in mandatory training. The registered manager is aware of this shortfall and has accessed a lot of training for staff over the next few months. The staff also need to receive more specialist training to ensure that they have the skills knowledge and capabilities to care effectively, positively and safely for the residents at the home. The manager has developed a training matrix so gaps can be identified quickly. There was evidence to show that all new members of staff receive an induction into the home and have an induction training programe in place.This has now been expanded and is in line with ‘Skills for Care’. The mangement has started to develop ways to check staff competencies after they have received training. Evidence of this was seen with regards medication knowledge and administration. Since a visit from the local contracting office in December ’07 the service has worked hard to improve their recruitment processes. Application forms are in place and completed. They now include a full employment history and gaps in employment are identified and explored. The interview process has been developed and questions and answer recorded. A medical questionnaire is in now place. 2 references are sought and a record is being kept if these have been validated with a verbal contact with the referee. The service is applying for CRB/Pova checks and for the majority of staff these were in place. However it was identified at the time of the inspection a member of staff was working in the home without POVA 1st check. This potentially leaves residents at risk. The manager was going to address this shortfall. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use the service experience good outcomes in this area The home is well run and in the best interest of the people who live there. The health, safety and welfare of the residents is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner is a qualified mental health nurse with experience of management within the NHS. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 23 She is making progress in reviewing and improving the services provided to the residents. She is aware of the shortfalls within the service and has plans for further improvements. The service has informed us that the registered manager/owner will be away from the home for 3 months starting in the middle of March ’08. During this period the deputy manager will be taking over the day-to-day management of the home. The service has told us that she will be receiving support and visits from the owners and the registered manager will be keeping in touch. The Registered Provider has told us that during this time the deputy manager will be supernumerary. Westleas has quality assurance systems in place. There are opportunities for the residents, staff, relatives and other stakeholder to put forward their views about the home and the standard of care that is offered. This is done using annual questionnaires. Feedback from the quality assurance has been collated and is available to read. This details how the service is monitored and feedback from consultations with the residents. The registered manager will be analysing the feedback and acting on any identified shortfalls. It should be ensured that this information is fully accessible for residents and their representatives to reference. Financial procedures are in place to safeguard resident’s monies. All staff have formal supervision on a regular basis. Staff said that they found this beneficial. Regular staff meeting also take place. Staff said that they feel listened to. They said that they can discuss any concerns with the manager or deputy. Policies are in place to strengthen safe practices. The home has informed us that all the relevant checks and inspection of equipment and system have been undertaken. An accident book is maintained. The deputy manager is in the process of up dating and developing environmental risk assessments .All fire assessments and checks are done. Water temperatures are not being monitored at the home. The registered manager told us this was on oversight. She told us that all the sinks and baths are thermostatically controlled. She said that she would ensure that water temperatures would be done and checked on a regular basis to ensure they are within the recommended limits. Westleas DS0000066037.V359536.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 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Westleas DS0000066037.V359536.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 OP7 Regulation 15(1) Requirement The manager develops and agrees with all residents user/representative an individual support/care plan, which includes all the health, social and personal care required, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations. The plan needs to be implemented and updated to reflect the changing needs of the residents. Daily records need to contain relevant information about the day of the residents and written in a format that is easy to follow. 2. OP8 12(1)(a) The registered manager needs to make sure all the health care needs of the residents are met. There needs to clear evidence in place to show how this has been done by the service. The service needs to make sure • Westleas Timescale for action 31/05/08 30/04/08 3 OP9 13 (2) 31/05/08 There is individual Version 5.2 Page 26 DS0000066037.V359536.R01.S.doc 4. OP27 18(1)(a) 5 OP29 19(4) (c) guidelines in place for residents prescribed ‘when required’ medication. • Topical creams need to be stored safely • The effects of pain relief need to be monitored. • People who self medicate need to have a risk assessment in place, which is reviewed at regular intervals. • People who self medicate need to be monitored at regular intervals to ensure they taking their medication as prescribed. The registered manager of the 31/05/08 home needs to make sure there is enough staff on duty at all times to meet the needs of all the residents. The service needs to make sure 31/03/08 that all staff working at the home have a POVA 1st and work under supervision until a full CRB check is obtained. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The service needs to make sure that they offer varied, meaningful and stimulating activities to the residents both in and out- side the home. The residents need to be involved choosing activities according their interests, preferences and capabilities. The service needs to develop a maintenance and renewal programme for the up-grade and redecoration of the home. The service needs to plan when they are going to DS0000066037.V359536.R01.S.doc Version 5.2 Page 27 2. 3. Westleas OP19 OP21 4. 5. OP22 OP38 renew/upgrade the bathrooms on the ground and 1st floor. To ensure they are able to accommodate the needs of the residents. The service needs to make sure it can use the necessary equipment available to meet the needs of all the residents staying at the home. The service needs to make sure that water temperatures are checked on a regular basis. Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westleas DS0000066037.V359536.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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