Inspection on 31/05/06 for Westleigh House

This inspection was carried out on 31st May 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westleigh House 21/10/09

Westleigh House 20/11/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Westleigh House 20 Chip Lane Taunton Somerset TA1 1BZ Lead Inspector Pippa Greed Key Unannounced Inspection 31st May 2006 1:10pm Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 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 House DS0000062992.V296442.R02.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 Adults 18-65. 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 House DS0000062992.V296442.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh House Address 20 Chip Lane Taunton Somerset TA1 1BZ 01823 284198 01823 350814 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) Voyage Ltd Emma Eveleigh Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person may be admitted in the LD(E) category. Date of last inspection This is Westleigh House’s first key inspection Brief Description of the Service: Westleigh House is a large two-storey property sited next to another Voyage home. The home is located in a residential area and is a reasonable walking distance from Taunton town centre. There is adequate parking and a new patio garden to the rear of the property. The home is registered with the Commission for Social care Inspection (CSCI) to provide personal care for up to twelve people between the age of 18 and 65 years who require care due to a learning disability and/ or physical disability. Westleigh’s condition of registration permits one named person aged over 65 in the learning disability (elderly) category. The responsible person is Stephen Ball. The registered manager is Emma Eveleigh. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection was conducted over two days (9hrs) by CSCI Regulation Inspector Pippa Greed. Jackie Dolan, Regulation Manager was present on the first day of the inspection. On the first day of the inspection, one deputy and five morning staff were on duty. The majority of service users living in the home were present during the visits. The Inspector and Regulation Manager met with three staff members, the manager and deputy manager. On the second day of the inspection, the Inspector viewed all communal areas and sampled several service users bedroom with informed consent. The Inspector met with and engaged with a number of service users. A selection of records was examined. The Inspector would like to thank the service users, staff, deputy and manager for their time and co-operation with the inspection process. Three requirements and five recommendations have been raised at this inspection. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Westleigh offers individualised care to service users with complex needs within a homely environment. Westleigh is a well presented and comfortable home. The home has recently acquired a new sensory light box for one of the service user. The garden has been refurbished with new decking area with raised deep bed and a water feature. The home ethos was apparent during the inspection process and service user’s rights and dignity were respected. A selection of files was sampled during the inspection. Westleigh has a robust medication administration system. Westleigh also maintains stringent records on accident and incident, which is supported by detailed risk assessment for each service user. Prior to the unannounced key inspection, the Inspector contacted and spoke with two family members regarding their son/ daughter’s care. The feed back were very good and all commented positively on the care and support offered by the Registered Manager and staff team at Westleigh. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 8 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 the following standard(s): 1, 2, 3, 4 The quality in this outcome group is good. The service user is supported when making an informed choice about moving to the home. The pre-admission assessment is clearly detailed. EVIDENCE: The Inspector viewed the Statement of Purpose, which was detailed and well written. Quality assurance within the service is detailed in the Statement of Purpose promoting best value and regular review of the service. The Service user Guide is provided in a generic format with pictorial symbols and easy to read descriptors. The home has recently admitted a service user and is currently setting up a care plan. The Inspector viewed the pre-admission assessment, which is good and provides details of the service user’s background. The service user’s previous home manager visited the home to discuss and support preparation for the transition. The service user appears to be settling in very well. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 9 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 the following standard(s): 6, 7, 8, 9, 10 The quality in this outcome group is good. The home’s care planning systems are clear and consistent. Service users are supported to make decisions and exercise choice in their day to day lives. Risk assessments are clearly written in the service users care plan. This promotes health and safety. EVIDENCE: The home has a key worker system in place. The manager informed the Inspector that service users meeting was implemented but felt this was not effective. The manager explained that the service user respond to decision making at their own pace rather than at a set time or frequency. The service users are supported daily with decision making and electing choices such as daily activity and mealtime options. Minutes of service users meetings are kept. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 10 The Inspector was told by the deputy when viewing the communal bathroom that a service user likes to view his weekly timetable when he takes his morning bath. The timetable supports the service user’s understanding of planned events. This promotes good practice. The Inspector viewed several care plans that were case tracked. The care plan evidenced that monthly summaries are maintained by key workers. This provides a regular audit and review of service users choices and aspirations. The service user’s likes and dislikes were listed in some files. A good example of a service user’s profile was seen in one care plan. This was shown in a new service user’s care plan. This serves as a good example of how best represent the service user’s personality and preferred lifestyle. The home would benefit from implementing this in all service users care plans. Risk assessments were detailed and well written. These risk assessments demonstrated that service users are supported to take informed risks within their agreed plan of care. However, some care plans do not distinguish between risk assessment and behaviour guidelines. The care plan would benefit from clearer sign posting of behaviour guidelines and daily routine guidance in order to help support new staff member and ensure consistency within the team. The care plans were stored in the office and can be accessed by service users and staff alike. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 11 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17 The quality in this outcome group is good. The home maintains adequate staffing level. The home provides a variety of leisure and social activities. The rights and privacy of service users are respected. Service users are offered a choice of menu that provides a balanced diet. EVIDENCE: The Inspector spoke with a staff member who explained that they have been made a key worker recently. Through this relationship and advocacy, the service user’s personal development has been supported. The service user has recently purchased a sensory water/ light display box for their own personal use. A new mattress has also been purchased which is having positive affect on the service user’s sleep pattern. This is to be commended. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 12 The service users access a range of activities such as bread making, music, art, cooking, massage, creative play, sensory room, horse riding, local walks, swimming, bowling, sailing, shopping, theatre, cinema, and pubs. The majority of service users go out shopping for their clothes. This was observed during the inspection process. For service users who choose not to go out clothes shopping, choices are offered through catalogue, photographic references, and family member involvement. Upon viewing one service user’s bedroom, the deputy informed the Inspector that the service user and their family was actively involved with choosing the colour and interior decoration. This is a good example of how service user’s wishes and choices are respected. One service user kindly showed the Inspector his bedroom. Whilst viewing his room, the deputy informed the Inspector that the service user is supported by the staff team to visit his mother, every few months. This provides important and meaningful contact with his family. All the bedrooms that were viewed during the inspection process were decorated in a personal way taking into account the service user’s preferred choice of colour and decorative theme. Many bedrooms had photographs of their family and friends adorned on the wall. Some service users bedrooms were fitted with keypad on the first floor. These are not being used by service users or staff and are currently unlocked. Copies of a four week menu were made available to the Inspector. The deputy informed the Inspector that service users are supported with menu choices using photos and pictorial symbols. The menu is prepared in advanced within a four week plan. Stocks were good. There is a flexible approach to meal planning, which allows for alternatives if requested. The main meal is prepared by staff. Some cooking activities have service user involvement such as bread making or help with kitchen chores. Fresh fruits and snacks are also available. The dining room is spacious, comfortable and very homely. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 13 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 the following standard(s): 18, 19, 20, 21 The quality in this outcome group is good. The home ensures that service users have access to appropriate health care professionals. The home’s procedure for the management and administration of medication is good. EVIDENCE: Staff support service users to meet their personal care needs in line with their agreed plan of care. During the inspection, staff was seen to be respectful and supportive with a service user’s personal care. The Medication Administration Record had a medical footnote including photographs of all service users and requirements when administering medicines, which promotes good practice. The Medication Administration Record showed no gaps and no variable dosage. Two staff signatures supported all hand transcribed entries. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 14 The care plan held letters received from health care professional answering queries relating to service user’s medication and whether it could be crushed or not. These letters demonstrates the care taken to check whether certain medicine is suitable for crushing or not. This is good practice. The last Pharmacy visit took place on 24th May 2006.The pharmacist advice given related to safe administration of medication and staff training. The home provides clear incident report in the service users care plan. This provides useful reference and clear audit trail when correlating with medication records. This also provides a monitoring tool for service users health. One service user has mental health needs. The staff team are aware of her needs and wishes. This was observed during the inspection process as a recreational in-house hobby was being facilitated to support the above service user. The home has link with the mental health professional. However, the home would benefit from mental health awareness training for the staff team. This would provide the staff team with specialist skills to meet the service users’ individual needs such as rehabilitation, treatment and recovery programmes, appreciation of, and ability to balance, the particular and fluctuating needs of the service user. One service user is insulin dependent. The care plan reviews the service user’s health. Regular contact with the local health care professional ensures that the medical needs are constantly monitored and reviewed. However, the home would need to ensure that all staff responsible for the administration of insulin and blood sugar monitoring receives annual practice up-dates. The home has had two deaths during the last 12 months. Appropriate actions were taken at the time. Voyage offered staff bereavement counselling in accordance with the company’s policy. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 15 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 the following standard(s): 22, 23 The quality in this outcome group is good. The home records complaints received and the outcome of each complaint. The home has policies and procedures relating to the protection of service users. Service users monies are recorded and stored securely. EVIDENCE: The Inspector viewed the home’s Adult Protection and Complaints procedure. The Adult Protection policy included local CSCI contact details. However, this was located in the Service User’s Guide. It would be helpful to have a file that is clearly labelled as Adult Protection to aid ease of access. The home’s Complaint procedure was seen and demonstrates appropriate timescale for responses and list of contacts. The home has a ‘Concerns, Complaint and Compliment’ file in place. The last complaint was July 2005 concerning a minor complaint, which was dealt with appropriately. Also included in this file were several complementary letters received from family members. The Inspector had spoken to parents as part of the inspection process. The parents spoken with stated that they knew who to contact if they had any concerns. They also confirmed that they received a copy of the last Inspection report. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 16 The families’ feedbacks were very positive. One parent’s opinion was that they felt very pleased with the service. They commented on the friendliness of the staff team and how helpful they were. The staff spoken with during the course of the inspection all demonstrated that they knew and understood the reporting procedure in the event of Adult Protection issue. The deputy informed the Inspector that the service users have a copy of the complaints procedure in Somerset Total Communication. Staff personnel file evidences that no staff has been recruited prior to Criminal Records Bureau clearance. Service user’s personal monies are checked daily. In a discussion with the deputy, only senior member of staff access the service users money. The senior staff member and staff member check together the final balance. The finance policy stated that two staff should sign. However, this is not always adhered to. A number of records sampled only showed one signature in several places. It is recommended that two staff sign all finance records when confirming the balance in accordance with the company’s policy. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 17 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 the following standard(s): 24, 25, 26, 27, 28, 29, 30 The quality in this outcome group is good. Service users live in a homely environment that is well decorated. On the whole the accommodation was clean, comfortable and homely. EVIDENCE: The Inspector viewed service users bedroom with informed consent. This included two lounges, dining areas, kitchen, office, bathroom and outdoor area. The home is arranged over two floors. Access to the first floor is via three staircases. The home accommodates one wheel chair user on the ground floor. The home has a lift in place but this is seldom used. It was noted that the middle staircase had a bar across the top stairway. This was fitted when the top floor was used as offices when Ashleigh and Westleigh operated as one home. This is no longer needed therefore should be removed immediately as it poses a hazard. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 18 The outdoor patio area has recently been fitted with new decking and guide rail. The garden features a trellis, raised flower bed and water feature. The decked area has a ramp for wheelchair access. The garden evokes a relaxing ambience and presents a seemingly popular and well-used communal space. The deputy informed the Inspector that barbecue days are anticipated in the summer months. The water feature would require risk assessment to determine whether a protective grill is needed or other preventative measures. The service users bedroom were decorated to their personal taste. Most bedrooms were fitted with television and offered comfortable seating area within the bedroom. The service user’s interests were exhibited be it through music collection, medals attained, model car collection, their own art work displayed, football memorabilia and photographs of their family. Some bedroom had shower en-suite and some bedroom had bath en-suite. All of which were provided with flip top pedal operated waste bin, paper towels, and liquid soap. All rooms were fitted with window restraint except for one. It is a requirement that an appropriate window restrictor is fitted. One service user’s en-suite toilet did not have a toilet seat secured. Although this en-suite is currently not used by the service user, it could pose a health and safety risk if another service user entered and used the toilet. The deputy has been informed. One spare bedroom on the first floor does not have a wardrobe fixing. This would need to be fixed in the event of a service user moving into the spare room. Communal areas, which are located on the ground floor, consist of two lounge areas, two dining areas, a medium sized well lit kitchen, and a large communal bathroom. The outdoor patio area can be accessed via one of the smaller lounge area. The small lounge currently houses a sensory water/light display unit belonging to one of the service user. The kitchen is of good size and is well equipped with a walk in larder. The larder felt very warm during the inspection. The deputy explained that staff sometimes open the larder door at times to help cool the larder. It is recommended that a cooling fan be installed. The bathroom was clean and presentable. There was a movable hoist sited in the bathroom to assist one service user with the toilet. The deputy informed the Inspector that a new window has been added which brings in natural light and improves ambience. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality for this outcome group is adequate. Staffing levels are sufficient in order to meet the needs of the service users. Staff receive mandatory training and some are undergoing NVQ studies. The home has a robust staff recruitment procedure. The home provides formal 1:1 supervision for all staff. The frequency is adequate. EVIDENCE: The home appeared to have sufficient staff on duty throughout the inspection. Some staff spoken with commented that staffing level does impinge on day trips and activities organised for the service users. A four week staffing rota was made available to the Inspector prior to the inspection. Staffing level appears adequate for the staffing/ service user ratio. The Inspector recommend that the management team continue to monitor and review staffing levels to ensure that service users are supported appropriately, especially at weekends and evenings. A newly recruited staff member had undergone a block induction training provided by Voyage. The staff member also received an induction workbook, Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 20 which details areas of learning. The staff member and manager liaise with one another to identify where to improve on staff’s knowledge base concerning service users daily living support. The staff team are provided with mandatory training annually. Some staff spoken with during the inspection process confirmed that they are currently completing their NVQ in Care. The manager would need to ensure that the current level of 27 is increased to the recommended 50 . Three staff personnel files were sampled during the inspection. These personnel records evidenced that no staff member have been recruited without a Criminal Records Bureau disclosure clearance. Staff spoken with demonstrated a clear understanding of the Adult Protection procedure and what constitutes as ‘abuse’. The registered person should consider recording the following details in order to provide clearer audit trail of CRB records: name of person who received it, signature and where stored. Staff were offered a formal 1:1 supervision on average quarterly. National Minimum Standards Care Standard Act 2000 – Standard 36.4 ‘Staff have regular recorded supervision meetings at least six times a year with their senior/ manager in addition to regular contact on day to day practice’. It is recommended that the home increase the supervision frequency. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42, 43 The quality in this outcome group is good. The home has good quality assurance systems in place. The home promotes health and safety in most areas of the service. The manager is experienced and manages the home well. The home has an experienced deputy manager who is acting up during the manager’s annual leave. EVIDENCE: The Inspector would like to thank the manager for coming in whilst on leave. The Inspector met briefly with the manager during the first day of the inspection process. The manager is experienced and has been registered under CSCI since 2004. The manager has attained NVQ level four in Management. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 22 Hot water outlets – records are kept daily throughout the home and in service user’s en-suite. The manager has arranged for an outside contractor to provide preventative measures against Legionella. Portable Appliance Testing was completed on 20/10/05. Fire - checks are being carried out weekly. The fire record contains a generic fire risk assessment but not a specific fire risk assessment for each room in the home. The last fire drill took place on 15/11/05. The manager explained to the Inspector the dilemma that fire evacuation drill poses. The drill can cause upset and increased behaviour in some of the service users. It is recommended that fire evacuation drill take place every three months maximising participation where possible, document and take into account service users who do not wish to be involved. Health & Safety – The home underwent a full Health & Safety workplace assessment in December 2005. This covered slips, trips, falls, manual handling, workstation and asbestos. Food Hygiene – Environmental Health last inspected the home on 28th July 2004. The staff completed daily fridge/ freezer temperature check, water outlet checks, cleaning schedule and food core temperature check. Accidents and incidents are recorded. A monthly analysis of accidents and incidents is undertaken. This clearly shows the number and type of accident or incident. This is good practice. Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 X 2 3 Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Not applicable 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. 2. Standard YA9 Regulation 13 (4) (a), (c) 13 (3) Requirement The registered person must ensure that the water feature is risk assessed. The registered person must ensure that the identified unused en-suite toilet is suitably covered to promote health & safety The registered person must ensure that suitable window restrictor is fitted in one identified bedroom area. Timescale for action 06/06/06 30/06/06 YA30 3. YA42 13 (4) (c) 31/07/06 Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA32 YA23 Good Practice Recommendations The registered person should take action to ensure that 50 of care staff achieves a minimum of an NVQ level 2 in care. The registered person should ensure as stated in company policy that two staff signatures are in place to confirm all service user’s financial transactions. The registered person should consider recording the following details in order to provide clearer audit trail of CRB records: name of person who received it, signature and where stored. The registered person should remove the stair bar on the first floor. The registered person should ensure that all staff receives training for the work they perform. This relates to training in diabetes and mental health issues. YA34 4. 5. YA24 YA32 Westleigh House DS0000062992.V296442.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Westleigh House DS0000062992.V296442.R02.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!