Inspection on 01/09/05 for Westleigh Avenue

This inspection was carried out on 1st September 2005.

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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westleigh Avenue 13/06/06

Westleigh Avenue 16/05/05

Westleigh Avenue 14/12/04

Westleigh Avenue 18/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Westleigh Avenue 45 Westleigh Avenue London SW15 6PJ Lead Inspector Sharon Newman Unannounced 1 September 2005 09:40 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westleigh Avenue Address 45 Westleigh Avenue London SW15 6RJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 030 8788 2111/435 020 8788 4356 Threshold Housing & Support Mrs Lorenza Hosten Care home only (PC) 14 Category(ies) of Learning disability (LD) registration, with number Physical disability (PD) of places Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: Westleigh Avenue is a purpose built care home registered for fourteen people with learning disabilities, seven of whom may also have physical disabilities. The building is single storey and is well designed for wheelchair users. All residents have their own bedrooms with a wash hand basin. There are four bathrooms in total consisting of: one assisted bathroom, two bathrooms with separate showers and one shower room. The home is situated in a quiet residential area of Putney with easy access to shops and facilities of Putney. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sharon Newman: Regulation Inspector Davina McLaverty: Regulation Inspector This unannounced inspection was conducted by two Regulation Inspectors and took place over one day on 1st September 2005. The Registered Manager was present throughout the inspection and staff members on duty were also spoken to. Records sampled included care planning documentation, health and safety information and medication records. A tour was also taken of the premises. Staff were welcoming and helpful throughout the inspection visit and displayed appropriate and caring interaction with the residents. The Registered Manager is experienced and has worked at the home for many years. She demonstrated a conscientious and enthusiastic attitude to her work and good knowledge of the residents’ needs. Many of the residents at this home present with challenging behaviours and some also have complex medical needs. Some areas highlighted in the previous inspection report have improved since the last inspection visit, this includes the overall cleanliness of the home. A redecoration programme has also commenced at the home. The manager also stated that staffing levels have improved since the last inspection and sickness rates amongst staff were improving. What the service does well: The Manager is experienced, approachable and well qualified and has a good knowledge of the residents at the home. Staff display a caring attitude to the residents and interact positively with them, showing respect for their dignity. Health needs are well met and there are very good links with local community health and social services which benefits the residents. One to one support is offered for those residents who require this input. Good day care support is offered to the residents who have the opportunity of attending day centres and work placements. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 7 contacting your local CSCI office. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5 The assessment process for prospective residents is thorough allowing a detailed care planning process to develop from this documentation. The home’s Statement of Purpose is good and provides prospective residents with details of the services offered. This allows them to make an informed decision about the home. EVIDENCE: The home has a Service Users Guide and this is also available as an audio cassette. The Statement of Purpose is comprehensive and includes information regarding: confidentiality, whistle blowing, person centred planning, admissions and key working. The Manager confirmed that a prospective resident has had the opportunity to visit the home and has undergone a detailed assessment process with the involvement of a multidisciplinary team. A Local Authority care assessment was seen to be in place at the home prior to this residents admission. The Manager stated she now has copies of all the residents’ contracts at the home. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 10 Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 There has been an improvement in the organisation and updating of residents’ care plans, however improvement still needs to take place in this area to ensure their needs are met. Although detailed, the care planning system is not clear and consistent enough to provide staff with sufficient information to meet the resident’s needs. EVIDENCE: Care planning documentation for three residents was sampled at this visit and some improvement was noted regarding this area at the inspection visit. However, although some of the documentation was more up-to-date information contained within the care plans was seen to still require review. Support plans were in place for all three residents and contained individual information including one-to-one support required, health and social needs, expenditure and enabling them to access the community. One support plan had not been updated since 08/07/04 and this needs to be reviewed. Each resident has a logbook where significant events are entered such as medical appointments, phone calls with relatives or any episodes of challenging behaviour. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 12 Risk assessments were in place and many had been updated recently, however some were seen to require review and this was discussed with the manager at the time of inspection. Risks considered included: violence, aggression, absconding, poor mobility and travelling outside the home. No evidence was seen of consultation with other professionals such as occupational therapists, social workers or nurses in drawing up these risk assessments. The Manager stated that a risk assessment was in place for one resident who requires bed rail equipment but had not yet been completed for two further residents needing this equipment. These risk assessments must be put in place. Information about residents was observed to be kept in a locked office to ensure confidentiality. Residents meetings were observed to be taking place regularly and to be fully minuted, providing evidence that residents’ views are sought on some issues. Issues discussed included holidays and menus. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 This home continues to ensure that links with the community are good and this helps to support and enrich residents’ work and social opportunities. Staff have a good understanding of residents support requirements ensuring these needs are addressed. EVIDENCE: Many of the residents at this home present with challenging behaviours and some also have complex medical needs. There are different levels of independence amongst the residents. Some residents are more mobile and independent and other residents require wheelchair assistance and have communication needs. Activities have to be tailored to meet all these different needs. The manager said that health and social care professionals from a local specialist unit are involved closely with many of the residents at the home and help to ensure that residents needs are assessed on an ongoing basis. Residents who require more input are assessed by a multidisciplinary team and are offered one-to-one support if it is required, one resident receives this daily. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 14 The manager reported that family involvement is encouraged. One resident spoken to said they were going out to lunch with a family member on the day of inspection. They reported that they enjoyed going shopping and listening to music. The manager commented that a befriending service is available for residents. Another resident said they did not like going out and preferred to stay at the home. This choice was seen to be respected. They said that they liked ‘doing puzzles’ and stated they enjoyed baking cakes and had been to a pub during the recent bank holiday. They indicated that they were satisfied with living at the home and were observed sitting at a table knitting with assistance from a staff member. Another resident was seen to be sitting out in the patio area with one of the staff members who was interacting with them tactfully and appropriately. Residents were observed to be treated with respect by staff on the day of inspection. Music and television equipment is available for the use of residents in the lounge area. There is also a smaller ‘quiet’ lounge at the home. The manager reported that three residents have recently been on a holiday to France and that another trip is being planned for residents to go to Wales. She reported that some residents like to go to the pub and also attend activity evenings organised by the Gateway club. Residents are given the opportunity to attend the Baked Bean Club which is a local drama group. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Health care needs are well met and there is evidence of multi-disciplinary input from health and social care professionals. Non-recording of allergies in the medication administration records could place residents at risk. EVIDENCE: Evidence was seen in the care plans of multidisciplinary input from healthcare professionals including: GP’s, physiotherapists, dieticians, speech therapists and hospital consultants. The manager reported that some of the residents have complex medical needs and she demonstrated a good knowledge of each individuals requirements. She said the home is supported by health and social care professionals based at a local specialist unit. The manager reported that staff have recently received teaching input from a London Hospital regarding one residents’ health issues. The medication cupboard was found to be locked securely. A medication policy is in place and there is also information regarding homely remedies, the Royal Pharmaceutical Guidelines are available in the home. Records are kept regarding medication coming into and leaving the home. Photographs of the residents were seen to be in place in the medication file to ensure they are easily identified. The allergies section on the medication administration records Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 16 was observed to be blank for some of the residents. This must be fully completed and where residents do not have allergies this must be noted. A bottle of medication was found to be labelled ‘as directed.’ All medication should be clearly labelled according to Royal Pharmaceutical Society Guidelines. Residents were noted to look presentable and appropriately dressed at the time of inspection. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Arrangements for protecting residents are satisfactory and policies and procedures are in place to protect residents. However, a lack of evidence regarding how issues have been resolved could place residents at risk. EVIDENCE: A complaints policy is available at the home and is also provided in a pictorial format. The Manager reported there had been one formal complaint since the last inspection and that one Protection Of Vulnerable Adults (POVA) investigation had also taken place. Discussions took place between the manager and the inspectors regarding the above issues. The inspectors were informed that the local Social Services department had investigated the POVA issue and no further action was to be taken. The inspectors were shown correspondence from social services regarding this issue. The inspectors found that progress of the complaint regarding the care of one resident was not clear. Although it is noted that some correspondence was in place, the incident was not logged in the residents care plan. Discussions took place about the importance of providing evidence and a clear audit trail for all complaints. A local authority Protection Of Vulnerable Adults policy and organisational abuse policy are both available at the home and a whistle blowing policy is also in place. As highlighted in the previous inspection report bed rail risk assessments are not yet in place for all the residents who require this equipment. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 18 A closed circuit television system monitors the entrance to the home as a security measure. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 Recent redecoration has improved the appearance of some areas within the home resulting in a more pleasant environment for the residents. There has also been an improvement as regards the cleanliness of this home. The redecorated bedrooms present as homely and the communal lounge/dining area provides residents with a comfortable environment in which to relax. However, the garden does not offer residents a pleasant environment in which to spend time and may present a risk to them. Areas within the home still require redecoration and attention. EVIDENCE: The inspections team recognise that it can be difficult due to the architecture of this home to ensure it offers a homely environment. However, evidence was seen that staff try to address this issue with the use of pictures and plants throughout the home. There has been a significant improvement in residents’ bedrooms in terms of meeting their needs. One resident has had a device fitted to their door to allow them to open it independently. Also, some bedrooms have been made more wheelchair accessible by the use of laminate flooring. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 20 Some bedrooms were seen to have been redecorated since the last inspection visit and they presented as more homely and comfortable. However, other bedrooms still require redecoration. One room that has been reserved for a new resident requires repainting. Also, a few light fittings throughout the home both in communal areas and bedrooms require lampshades. A new shower room/WC has been completed allowing easier access for wheelchair users. Adapted beds, washing facilities and washbasins are available at the home and help to meet the resident’s needs by enabling them to be more independent. The communal dining and lounge area was seen to be clean, light and spacious with solid and attractive furniture. There is a photo board of the residents in this area which helps create a homely feel. The pool table lounge has had new lampshades fitted. Improvements have taken place regarding the cleanliness of the home since the last inspection visit and overall the home presented as clean and hygienic. However, one residents’ room still smelt strongly of urine. It is acknowledged that the manager is aware of this and has been trying to address the problem. The manager reported that she was going to liaise with the continence advisor for advice again about this issue. Staff reported that the dishwasher is broken, this must be repaired or replaced. Crockery must be washed at sufficient temperatures to meet infection control standards. Also, in a home of this size consideration must be given to ensuring staff are spending their available time with residents and not washing up crockery. The manager said that the home has been having problems with the hot water pressures at the home and that water has been running at cold temperatures. She reported that the water pressure to the Parker bath is often ‘a trickle’. This issue must be addressed. The garden presents as unattractive as it remains largely overgrown and untidy. Also many of the paving slabs were observed to be uneven which could present a risk to the residents. It is acknowledged that staff have tried to address the issues in the grounds by placing attractive plant containers in the garden and encouraging residents to tend a vegetable patch. These issues were discussed with the manager at the time of the visit. The employment of a gardener would be of benefit to the home and to the residents to ensure they have an attractive, safe and usable outdoor environment to enjoy. Also, consideration could be given to sectioning off part of the garden for the residents use. This area could then be given priority as regards maintenance. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 21 The manager stated that a new front door has been fitted and that a new call bell system is to be installed throughout the home within the next three months. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36 Staff are caring and committed to delivering good standards of care and they have a good knowledge of residents’ needs. Evidence of up-to-date staff training needs to be in place to ensure residents are supported by appropriately trained staff. EVIDENCE: The manager stated that staffing levels and sickness rates have improved since the last inspection visit. She said there is one full-time vacancy at the home. She said the shortfall is currently covered by agency staff and that they try to ensure continuity for the residents by using the same staff. Two domestic staff are employed and their hours together total 26 per week. The manger reported that 6 hours would be lost from one of the posts. Using increased care staff hours would then cover this shortfall. The home needs to ensure that standards of cleanliness do not decline again in the future. One agency staff member spoken to said this is ‘one of the best homes’ because staff give residents choice regarding daily living activities including choosing clothes. They reported that this is a good place to work and they are well supported by the manager and the deputy staff are also good. Another agency staff member said they were up-to-date with their mandatory training and had received this through their agency. They said they enjoy interacting with the residents and building up relationships with them. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 23 Sufficient numbers of staff were seen to be on duty at the time of inspection and staff were seen to interact appropriately and respectfully with residents throughout the visit. The Manager reported that although two staff have undertaken the NVQ Level 3 qualification they have not yet completed this due to ‘issues with the training system’. Also, although staff spoken to said they had undertaken many of the mandatory training courses there was not enough documentary evidence to support this. A staff training log would help to provide evidence that training is taking place in areas such as first aid, moving and handling, fire safety, food hygiene and medication. The frequency of staff supervision is improving, however not all staff are receiving one-to-one supervision and this needs to be in place. Documentary evidence was seen to show that staff meeting stake place regularly and are fully recorded. Issues noted to be discussed include: health and safety and training appraisals. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 42 The manager has a good understanding of any areas at the home needing improvement. She is experienced, enthusiastic and well qualified; her management style is open, and positive. She has a good knowledge of all the residents. The systems for resident consultation have not been fully implemented with little evidence that their views are sought by the organisation. EVIDENCE: The manager is very experienced and has worked at the home for many years. She said she has obtained the Registered Managers Award and is completing a qualification in NVQ Level 4. She demonstrated a good knowledge of the residents including their needs, likes and dislikes. She also displayed a strong awareness of the strengths and requirements of the staff team at the home. The manager highlighted that the home was going through a period of change at present. She reported that policies and procedures are changing due to the Provider Organisation merging with another. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 25 As found at the previous inspection the quality assurance programme has yet to be fully implemented. This needs to be put in place to ensure residents, relatives, professionals and stakeholders have a voice in the running of the home. As found at the previous inspection visit a legionella testing certificate was not in evidence at the time of inspection. This must be obtained. Documentary evidence confirmed that the electrical installation and gas safety inspections are up-to-date. Fridge and freezer temperatures were found to be in order and are recorded twice daily. Water temperatures were seen to be recorded weekly. An up-to-date certificate for portable appliance testing could not be found at this inspection and this needs to be obtained. The inspectors were informed that the Regulation 26 Providers visits are taking place however there was not enough documentary evidence available to support this as there were only three reports available. Copies of these visits must be in place at the home and also sent monthly to the CSCI. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 x x x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westleigh Avenue Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 27 YES Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 (1) (2) 12 (1) 13 (4) Requirement The Registered Person must ensure that information in the service user care plans is kept up-to-date. The Registered Person must ensure that: 1. Risk assessments must be put in place for the use of bed rails at the home and must be regularly reviewed. (Timescale of 31/05/05 not met) 2. Risk assessments are regularly reviewed and demonstrated involvement from other professionals. The Registered Person must ensure that the allergies section in the Medication Administration Records is fully completed. Where no allergies are known this should also be indicated. The Registered Person must ensure that complaints are fully recorded with clear actions taken documented. The Registered Persons must ensure that all maintenance items as outlined with Standard 24 of this report are attended to. Timescale for action 01/11/05 2. YA9 01/10/05 3. YA20 13 (2) 01/10/05 4. YA22 17 (2) Schedule 4 23 (2) 01/10/05 5. YA24 01/12/05 Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 28 6. YA35 18 (1) 7. YA35 18 (1) (a) 12 (1) (a) 12 (5) (a) 8. YA36 18 (2) 9. YA39 24 (3) 10. YA39 26 11. YA42 13 (4) The Registered Persons must ensure that a staff training log is kept to provide evidence that staff attend regular training updates. This is with particular reference to first aid, manual handling and food hygeine. The Registered Provider must ensure there are at all times sufficient numbers of trained and experienced staff at the home to meet the needs of the service users. The Registered Persons must ensure that all care staff receive a minimum of six supervisions annually (pro-rata for part time staff). Full records must be kept to evidence this provision. (Timescale of 30/06/05 not met). The Registered persons must ensure that the system in place for reviewing the quality of care provides for consultation with service users and their representatives.(Timescale of 30/06/05 not met). The Registered Person must ensure that both the Home and the Commission for Social Care Inspection are supplied with copies of the monthly Provider Visit Report. The Registered person must ensure that an up-to-date Portable Appliance Certificate is obtained. 01/11/05 01/10/05 01/11/05 01/12/05 01/11/05 01/10/05 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 G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 29 Westleigh Avenue 1. YA20 2. YA24 The home should request the prescriber of any medication for service users to write full and precise instructions on the prescription. The use of ‘as directed’ should be avoided as per Royal Pharmaceutical Society Guidelines. The home should consider the employment of a gardener/maintenence person for the home. Westleigh Avenue G54-G04 S10237 Westleigh Av V242705 010905 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Raod Wimbledon SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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