Inspection on 09/11/06 for Westleigh

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Westleigh 24/02/06

Westleigh 10/09/05

Westleigh 10/11/04

Westleigh 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westleigh 17 Summerhill Terrace St George Bristol BS5 8HX Lead Inspector Sandra Gibson Key Unannounced Inspection 9th November 2006 11:15 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 Westleigh DS0000036976.V319218.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. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh Address 17 Summerhill Terrace St George Bristol BS5 8HX 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) 0117 9031062 0117 9551271 Bristol City Council Mrs Sandra Delves Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Westleigh is a local authority care home managed by Bristol City Council and is located in the residential area of St George. It provides accommodation for up to 40 individuals and is registered to provide personal care for older people aged 65 and over. There are a number of communal areas including dining room, small lounges, and garden and patio area. The home is on two floors with lift and is fully equipped to meet the needs of residents. Fees are £451.99 per week and extra charges are made for chiropody, hairdressing etc. Currently this information is initially only provided verbally prior to admission. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place midweek between the hours of 11:15 am and 5 pm. Evidence was gathered from: Examining previous correspondence with the home including Regulation 37 (Death illness, other events notifications) and Regulation 26 monthly reports complied by the nominated responsible individual, inspection reports, information from pre inspection questionnaire, information from an independent survey of the home conducted in September 2006, residents’ questionnaires (40 sent 20 received) relatives comment cards (40 sent 9 received), GP comments cards (5 sent 1 received) talking to/observing residents, talking to two assistant officer/talking to and observing staff, talking to one visitor, talking to and case tracking four residents, examining records, policies and procedures. What the service does well: The service carefully considers the needs assessment for each individual prospective resident before agreeing to admission . This allows residents and their relatives to make sure that Westleigh can meet their individual needs. The medication administration system in place is satisfactory. There are safeguards in place to protect residents from harm. The health care needs of residents continue to be well met with evidence of good multidisciplinary working taking place on a regular basis. The residents of Westleigh are given the opportunity to experience a stimulating and varied life where various informal activities and outings are regularly made available in a setting that promotes independence and choice Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. The complaints system in place is good which ensures that residents and their relatives continue to be confident that their concerns will be listened too and acted upon Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 6 Westleigh continues to be a clean, comfortable, safe home, which ensures that residents are kept safe from harm. Staffing levels at night and during the day are satisfactory with a result that residents’ needs are met at all times The staff training programme is on the whole satisfactory which ensures that residents’ needs are met. The residents and staff team continue to benefit from an experienced manager who has encouraged an open style management approach. Support to staff is good. The systems in place now ensure that residents benefit from staff that are appropriately supervised. There are satisfactory systems in place to ensure those residents’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. What has improved since the last inspection? What they could do better: Information about the home provided to residents and their representatives have been updated since the last inspection .A minor amendment is outstanding which would ensure that new residents and their relatives can make informed choices about the home and that they can be sure their rights will be safeguarded. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 7 The majority of care plans and individual risk assessments continue to be of a good standard and that residents are treated with dignity and respect at all times. However, a very small sample indicated that a residents fluctuating needs had not been fully identified. Further development of needs assessment, care plans and risk assessments is required to ensure that individual’s specialist needs are fully identified and met. 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. Westleigh DS0000036976.V319218.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 Westleigh DS0000036976.V319218.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): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home provided to residents and their representatives have been updated since the last inspection. A minor amendment is outstanding which would ensure that new residents and their relatives can make informed choices about the home and that they can be sure their rights will be safeguarded. The service carefully considers the needs assessment for each individual prospective resident before agreeing to admission. This allows residents and their relatives to make sure that Westleigh can meet their individual needs. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 10 EVIDENCE: Evidence confirmed that the Statement of purpose and service users’ guide have been updated since the last inspection. The intermediate Care Service, which started operating in February 2005, is now no longer provided. There is however a recent application with The Commission for social Care Inspection to increase the number of residents that can be accommodated to fortytwo/forty- three. As discussed at the last inspection the statement of purpose stipulates that in exceptional circumstances and extreme cases people less than 65 years but not younger than 55 years can be admitted. This can only take place following an application to vary the age range, which must be agreed with The Commission for social Care Inspection. This information must be made clear in the Statement of purpose and service users guide. Also details of the cost of the placement should be made available in the service users guide. Westleigh are currently in the process of transferring nine residents from another Local Authority care home, which is closing. A sample of needs assessments obtained prior to these residents being admitted to Westleigh were seen on residents’ files. They were found to be up to date and accurate and included full details of the individual residents’ assessed needs. There was evidence in place to confirm that staff were well briefed on the needs of the new residents. One new resident said that she was settling in very well. I feel very positive about the home and have been made to feel very welcome”. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of care plans and individual risk assessments continue to be of a good standard and that residents are treated with dignity and respect at all times. However, a very small sample indicated that a residents fluctuating needs had not been fully identified. Further development of needs assessment, care plans and risk assessments is required to ensure that individual’s specialist needs are fully identified and met . The medication administration system in place is satisfactory. There are safeguards in place to protect residents from harm. The health care needs of residents continue to be well met with evidence of good multidisciplinary working taking place on a regular basis. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of care plans and risk assessments were seen and it was observed that the majority were very clear well detailed and there that there was evidence in place to confirm that they were reviewed on a regular basis by the manager in consultation with the resident, their representative where possible and the residents named key worker. However, there were a very small number of care plans and risk assessments where resident’s conditions had changed and the change in needs had not been fully reassessed. During the course of the inspection the inspector had the opportunity to speak to one resident’s key worker at length about the support she had provided to a new resident who was settling into the home. The resident in question has increased mobility needs. The member of staff showed very good awareness of meeting this resident’s needs with dignity and respect. Evidence confirmed that Bristol City Council medication policy and procedure are in the process of being reviewed. The nominated responsible individual is a member of the multidisciplinary working party. This process is almost completed. Staff are aware of and understand current guidance. Staff follow robust systems to make sure that medication records are fully completed. The home has a good record of compliance with administration, safekeeping and disposal of controlled medication. A sample check of medication administered to residents was undertaken. It was noted to be satisfactory. The inspector observed the staff during the course of the inspection and noted that they continue to have a good rapport with the residents. One resident with a sensory impairment said, “Everybody is good. I feel safe and secure. Staff check me at night.” Another resident said “ The staff always contact the doctor for me if I am unwell”. A third resident said” They are very patient even when I am frustrated and cross because I cannot do the things I used too. Comments received from relatives included “ My sister and I are very happy with the way our mother is looked after”. Another relative said, “ I think Westleigh is a very good home. They take care of my father very well especially considering his sometimes erratic behaviour”. A third relative said “ I am very happy with the care mum receives. She is always clean and her health is monitored well. There was evidence in place to confirm that General Practitioner’s, psychiatrists, the mental health” in reach “service, district nurses, opticians, dentists and chiropodists are all contacted at the appropriate time. Records all confirmed that residents were assisted to attend hospital appointments where planned. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. Positive feedback was received from the one completed GP comments cards received. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 13 The home has clear and robust practices for the care of residents who are dying. This was confirmed in Regulation 37 notifications sent to The Commission for social care Inspection in respect of residents who had died since the last inspection. Westleigh DS0000036976.V319218.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents of Westleigh are given the opportunity to experience a stimulating and varied life where various informal activities and outings are regularly made available in a setting that promotes independence and choice Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: There is a programme of activities twice a day one hour in the morning and one hour in the evening (Monday to Friday) and once a day at the weekend in the evening. Care staff also work with individual residents during (key time). Individual key workers make themselves known to residents and family members. Several residents seen during the inspection confirmed this. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 15 Live entertainment is usually musical is held in the home every two to three months. There is a diary of activities available to view on the notice board on the door leading in the dining room. This information was confirmed by the photographs in the home of residents and staff involved in activities such as Summer excursions and BBQs. The inspector heard about regular outings to places of interest such as Brean and Weston- Super-Mare. Evidence was also confirmed in the sample of service users care plans seen. A couple of residents talked about visiting the bar, which is, open each evening. One resident said, “I like the evenings in the bar because they are nice and jolly.” On the day of the inspection a game of dominoes was held in the dining room after the communal lunch. There is a library facility, which is accessible to all residents as it is situated in one of the hallways on the ground floor. Books are changed every six weeks. All residents observed during the inspection looked relaxed with the staff providing their care who were observed to respond to the residents in a respectful unhurried manner. Residents spoke very positively about their key workers and time they spent with them. Evidence confirmed that a key objective for the home is for residents to maintain independence and be enabled to make their own decisions about how they whish to live. Menus were inspected and were found to be balanced and appetising. Meal times are also flexible enough to accommodate individual preferences. Evidence confirmed that some residents choose to eat in their bedrooms. The inspector joined in the relaxed communal lunch held in the dining room. Residents were seen being assisted by staff members to make choices about the meal they wanted .One resident talked about her diabetic diet. The four residents the inspector sat with confirmed that they liked the food and that there was plenty of choice available. New residents spoken to during the course of the inspection confirmed that they enjoyed the food provided. There was evidence of fresh fruit and vegetables provided on a regular basis. One of the residents said, “definitely lovely food here” The residents confirmed that the provision of in between drinks and snacks are very good and that their families are made very welcome when they visit. A relative was observed having lunch with one of the residents during the course of the inspection. The relative seen said “you can place me here any time“. Westleigh DS0000036976.V319218.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints system in place is good which ensures that residents and their relatives continue to be confident that their concerns will be listened too and acted upon Following the last inspection urgent attention was given to the system in place for protecting residents from possible risk or harm. The system in place now ensures service users are protected from abuse. EVIDENCE: Relatives and staff confirmed in the surveys received that they were comfortable talking to the manager or one of the management team about any concerns. Residents were seen actively seeking out the members of the management team on duty that day with any concerns they had. One resident said “ I would speak to an officer or the manager if I had any concerns but I am happy here.” Another said she would talk to her key worker or the management team in the office. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 17 A relative said that s/he had made a complaint about the care of her relative and confirmed that she was satisfied with the out come. “I am satisfied that an improvement has been made, but will continue to monitor this in case of regression”. Another relative told the inspector that s/he and her family had raised concerns about the care of their relative but were happy with the outcome and how the manager had dealt with the situation. No complaints have been received either by the manager, the complaints officer for Bristol City Council Adult Community Care or The Commission for Social Care Inspection since the last inspection. No Secrets in Bristol (Local authority Adult Protection procedure) is in place in the home. There was information to confirm that the management team and all staff members have attended adult protection training organised by Bristol City Council Safeguarding Adults Coordinator since the last inspection. There is an ongoing adult protection-training programme in place. Residents are encouraged to take responsibility for their own financial affairs. Support is provided to residents who need help in financial matters. The use of the policy in place has recently been reviewed by the management team following an investigation into an allegation of financial abuse by a staff member. The system in place has now protect residents from financial abuse and directs staff in their practice. A resident and their relative seen at the time of the inspection confirmed this. Westleigh DS0000036976.V319218.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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westleigh continues to be a clean, comfortable, safe home, which ensures that residents are kept safe from harm. EVIDENCE: The inspector was updated about the changes in the environment since the last inspection. Evidence confirmed that disabled access has improved with the installation of a new wheelchair accessible shower room. Security to the home has also improved. Three bedrooms have been opened up in preparation for the increase in number of residents to be accommodated. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 19 In general, the environment is well maintained and suited to residents needs. Westleigh is decorated and furnished to a standard that creates a comfortable homely atmosphere despite it being a purpose built building. There is a programme of redecoration and refurbishment to further improve the environment. Comments were received from residents such as “It is the cleanest care home my daughter has ever looked at when she was trying to place me after my wife died” There are a number of small lounges through the home in the care home which residents were seen using and appeared comfortable and relaxed. The home smelt fresh and the rooms were cleaned to a high standard. Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and furniture. The toilet and bathroom facilities are sufficient to meet the needs of the residents. The garden at Westleigh is maintained to a high standard. This is done with the assistance of one of the residents and his son who also cares takes the greenhouse where various plants, including tomatoes and other vegetables are grown and are used in the kitchen for the residents in the home. Westleigh DS0000036976.V319218.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): 27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at night and during the day are satisfactory with a result that residents’ needs are met at all times The staff training programme is on the whole satisfactory which ensures that residents’ needs are met. EVIDENCE: From the evidence received during the inspection residents and relatives confirmed that they have confidence in the staff that care for them. This was confirmed in the service users surveys and relatives comment cards. One resident said, “I am very happy here and my family are happy with the care I receive”. Another said, “All carers should be highly praised for their care and dedication especially …who is my key worker”. One relative said “I am very happy with the care my mother receives. She is always clean and her health is monitored well”. Another relative said “My mum has been at Westleigh for four years. She has had good care and is very happy. Staff are all very nice and helpful”. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 21 Rotas show that the home is staffed efficiently with particular attention given to busy times of the day and changing needs of residents. A high level of agency staff are used to fill the gaps in the rota but evidence confirmed that the same staff were used where possible to ensure a consistency in the care provided to residents. Evidence confirmed that this use of agency staff was monitored by the manger. The inspector was informed that permanent staff are to be redeployed to the home following the closure of another local authority home. The manager ensures that all staff receives relevant training that is targeted to meet the needs of the residents accommodated in the home. The recruitment procedure was not inspected during this inspection as the staff personnel files are held centrally by Bristol City Council Adult Community care personnel department. These files will be inspected separately following an agreement between Bristol City Council Adult Community Care Team and The Commission for Social Care Inspection. Westleigh DS0000036976.V319218.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): 31,32,33,34,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and staff team continue to benefit from an experienced manager who has encouraged an open style management approach. Support to staff is good. The systems in place now ensure that residents benefit from staff that are appropriately supervised. There are satisfactory systems in place to ensure those residents’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. Following the last inspection improvements have been made in respect of making the records available for inspection. The system in place now ensures that residents and staff health and safety is fully protected at all times. Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager was not present during the unannounced inspection. However, evidence confirmed that she has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running the home. All staff and relatives consulted confirmed that the manager continues to be very approachable and supportive. Regular staff meetings take place. Staff confirmed this information. One member of staff said if you cannot attend the meetings any issues you wish to raise are brought up for you. Records confirmed that staff supervision is taking place on a regular basis for all members of staff. The care staff and domestic assistants on duty confirmed this that day that all said that they felt very well supported and that the officer responsible for their individual supervision was very approachable, A sample of records that is required to be available for inspection was found to be secure and well maintained. The fire log was examined. All periodic checks and tests were found to be up to date and that day and night staff receive fire safety training as out lined in the recommendations by Avon Fire Brigade The Commission receives regular reports for Social Care Inspection from the nominated responsible individual who conducts monthly visits to the home. The system in place for carrying out and reporting these visits is currently being reviewed. The financial arrangements for managing residents finances and valuables is satisfactory Westleigh is operated by Bristol city Council and the registered person has the skills and ability to deliver good business planning effective financial controls and provides a quality assurance and monitoring process. Westleigh DS0000036976.V319218.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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Westleigh DS0000036976.V319218.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 OP1 Regulation 6 Requirement The Statement of purpose/service users guide must be very clear about the age range of residents that can be admitted. It must also contain information about the costs of the service Care plans must be kept under review with the service user and family where appropriate. They must up dated with full details of changed needs (including risk assessment) Timescale for action 31/01/07 2 OP7 15(2)(b) 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Westleigh DS0000036976.V319218.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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