Inspection on 01/11/07 for Westleigh Lodge

This inspection was carried out on 1st November 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Westleigh Lodge 17/11/08

Westleigh Lodge 26/06/08

Westleigh Lodge 25/10/06

Westleigh Lodge 15/05/06

Westleigh Lodge 05/12/05

Westleigh Lodge 11/05/05

Westleigh Lodge 04/10/04

Westleigh Lodge 15/04/04

Westleigh Lodge 21/11/03

Westleigh Lodge 27/05/03

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

CARE HOMES FOR OLDER PEOPLE Westleigh Lodge Nel Pan Lane Leigh Lancashire WN7 5JT Lead Inspector Judith Stanley Unannounced Inspection 1 November 2007 08:15 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 Lodge DS0000005703.V345561.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 Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh Lodge Address Nel Pan Lane Leigh Lancashire WN7 5JT 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) 01942 262521 01942 674783 westleighlodge@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Miss Michaela Marie Keeley Care Home 48 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (48) of places Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 48 service users, to include: Up to 48 service users in the category of DE(E) (Dementia over 65 years of age); Up to 3 service user in the category of DE (Dementia under 65 years of age) may be accommodated within the overall number of registered places The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 25th October 2006 2. Date of last inspection Brief Description of the Service: Westleigh Lodge is a purpose built three-storey nursing home that offers care for up to forty-eight people of either sex who are suffering with a dementia related illness. The Home is owned by Southern Cross Health Care and is situated on the outskirts of Leigh town centre. The Home is within easy reach of local shops and other amenities and is well served by public transport. There is a car park to the front of the Home and gardens at the rear. Accommodation is provided on the ground and first floor; both floors have a communal lounge and dining rooms. All residents have a single room with en suite facilities. Bathrooms and toilets situated are on both floors. There is a passenger lift to all floors; the third floor houses the homes kitchen, laundry and staff room. Residents do not access this area. The current rate of fees at Westleigh Lodge is £325.55 per week. Additional charges are made for hairdressing and chiropody. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a site visit which the home did not know was going to happen and was conducted over a period of 7½ hours. Part of the time was spent with the manager in the office looking at the paperwork that the home needs to keep about the care of the residents (care plans) and the running of the home. Throughout the course of the day the inspector spoke with staff, residents and visitors. Prior to the inspection the home was sent an Annual Quality Assurance Assessment (AQAA) to complete. This information informs the inspector of how the home has met the National Minimum Standards and what has improved since the last inspection and in which areas the home feels it still needs to improve on. To gather further information about the home comment cards were sent to residents, relatives and other people who visit the home such as doctors and district nurses. Three health care professionals returned comment cards, one said, “The home could be improved by using regular staff and not locums (agency) but the home cares for clients well”. One doctor said, “ They are a caring service and I have a very good relationship with them, there are no improvements needed at this present time”. Seven residents comment cards had been completed, however members of staff assisting residents completed them all. Due to the dementia related illness, which residents in this home suffer from it is difficult for them to communicate how they feel about the home and the services provided. It may be beneficial if an outside advocate tried to complete any questionnaires with residents to obtain an independent view. Four relatives returned comment cards, one said, “I am satisfied with the general provision for my sister”. Another said, “When someone you love has to go into care it is hard to know which is the best, but here I think my mother has the level of care which I could give her if I was well enough. The home offers peace of mind for myself and my sister, to know that mother is safe and clean. The support we have had from the home is way above the call duty and we think of them as an extended family”. There has been two concerns brought to the attention of the manager, these were suitably dealt with and the outcomes recorded. There have been no complaints or concerns forwarded to the CSCI. At the end of the inspection two immediate requirements were made. An immediate requirement is made when the inspector has concerns about certain issues and the manager or a representative of the company must inform the CSCI within 48 hours how these issues are to be addressed. The first immediate requirement was made as the company had failed to carry out Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 6 monthly monitoring visits and provide a copy of their report to the manager and have the report available for inspection. This requirement was outstanding from the last inspection of the 15 May 2006. The second immediate requirement was made that the corridor carpet was dirty and heavily stained; this was outstanding from the last inspection. The downstairs also has an odour of urine, which permeates around the ground floor and is offensive. Failure to comply with the above requirements may lead to enforcement action being taken. These requirements are not the fault of the home’s manager, as they need to be addressed at a more senior level. What the service does well: What has improved since the last inspection? The odour problem on the first floor has been eradicated. A new carpet has been fitted on the corridor on the first floor. All bedroom doors had been brightly painted, fitted with a letterbox, number and doorknocker to enhance memory for residents to locate their own rooms. The manager has introduced two meal sittings to ensure that residents receive the help they need and that there is more room in the dining room and a more relaxed atmosphere. Support staff are working in the home 24/7 assisting one resident. Staff training had improved to enable staff to understand the different types of dementia and changes in behaviour that occur and how to deal with these changes. There is better signage to assist in residents moving around the home. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 7 Several areas of the home had been decorated, and new tables and chairs had been ordered and were to be delivered next week. A telephone call from the suppliers verified the date of delivery during the inspection. The range of activities available has improved, offering more variety for residents to take part in. A bar and tap room theme has been built in one of the lounges, this is near completion and then residents will be have a pub lunch, play dominoes and socialise with others as though they had gone out of the home to visit the pub. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westleigh Lodge DS0000005703.V345561.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 Lodge DS0000005703.V345561.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): 2, 3 and 4 were assessed. Standard 6 does not apply as the home does not provide an intermediate care service, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters can be confident that the home and staff can meet the specialised care needs of the residents as detailed in the information provided prior to admission. EVIDENCE: All residents on admission to the home are provided with a written contact/statement of terms and conditions regardless of how their care is purchased. Four care plans were chosen for inspection. On examination all contained a pre admission assessment to ensure that the prospective residents health, personal and social care needs can be met and that Westleigh Lodge is the Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 10 appropriate place for the resident. On admission to the home a more in depth dementia assessment is carried out to see at what stage the residents dementia is at, what the residents capabilities are and what skills the residents has retained and lost, for example can they dress themselves, level of communication, sleep patterns, mobility and eating patterns etc. Since the last inspection several staff have undertaken training in dementia care. Four staff has also attended the training course Yesterday, Today and Tomorrow (training devised by the Alzheimer’s Society). All staff is to receive this training. The manager and staff feel that they are now more aware of the different types of dementia, the changes in resident’s behaviour patterns and are more confident in dealing with and understanding residents Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were clear and provide staff with the information they need to make sure that can meet the individual’s care needs fully. EVIDENCE: Four care plans were chosen for inspection. The information contained in the care plans gave staff detailed information about the care each resident required. It is important to keep the information up to date as most of the residents living at Westleigh Lodge would not be able to communicate fully with staff to express their views and opinions, whether they liked something or not. The care plans contained residents personal details, pre assessment information, details of medication, what personal care is required, a physical and social assessment, a social profile such as family background, which school they attended, where they worked, pastimes and hobbies etc. Files should continue to be updated at least monthly and there was evidence to show when Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 12 either a three monthly or six monthly were booked for. At the last review for one resident he attended the review meeting with his relative. Other information in the care plans included risk assessment, for examples risk of falls and mobility, nutrition, pressure care and moving and handling. There was information to demonstrate in the care plans that outside agencies, such as doctors, speech and language therapist and the continence advisor visited the home as required. There was also evidence support workers assist with 24/7 care for one resident Observations throughout the inspection showed that the personal care needs of the residents were being met. Residents were nicely dressed and well groomed and ladies had had their hair done. Resident’s bedroom doors are open during the day and although residents move freely around the floor they live on they were not seen constantly going in other resident’s rooms. Staff when assisting residents with toileting did the task efficiently making sure that resident’s dignity was maintained. Staff were heard speaking with residents in a friendly and caring manner. The nurse in charge of each floor administers medication. The inspector observed the morning medication round on the ground floor and watched the nurse give out the medicines in an efficient manner, offering water with the tablets and then recording the appropriate information on the individuals drug sheets. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A wide range of activities is offered for residents to join in with if they wish. EVIDENCE: The activities coordinator post is currently being covered by another member of staff. There is a wide and varied range of activities provided and the activity programme is available in the foyer so that relatives can see what is going on in the home and they are welcome and encouraged to come along and join in. There had been a Halloween party the day before the inspection and the activities coordinator had taken photographs and had transferred them so that they could be shown on the television in the lounge. It would appear from seeing the pictures that residents had had a good time. Other activities include art, colouring and crafts, bingo, ball games to promote exercise and coordination and a movie afternoon. Resident’s also go on shopping trips to the local supermarket, to other local shops and enjoy one to one time. The home also has the use of a company’s mini bus, which is shared between several homes when required. Activities are recorded in residents files but the Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 14 system used limits space for comments such as if the resident enjoyed the activity or not. On the AQAA information the manager wishes to introduce during the next year, several ideas for involving residents and offering them more stimulation such as corridors on both units to have a market theme, with four market stalls to be built along the corridors, one stall with fresh bread and cakes which residents will be able to enjoy the produce of when walking around. A haberdashery stall with keys, handbags, purses and wallets, buttons, balls of wool and more to be provided for residents, to provide stimulation and aid memory. A cake and sweet stall, cakes that residents can assist in making and soft sweets, and a newsagents stand, magazines, papers and books to be made available so that residents can look at them if they so wish. As previously stated the bar/tap room area is near to completion. These ideas if and when in place will hopefully increase mobility for some residents, enhance calorific intake for others and for some, be a trip down memory lane. Visitors are welcome to visit the home at any time; there are no restrictions as to when people visit. Some visitors like to come at lunchtime and assist in helping feed their relative. Residents can meet with their visitors in the lounges or in the privacy of their own rooms. Where possible links with the local community are encouraged and maintained. Residents choices are taken into consideration, this very much depends on the capacity residents have to make those choices and decisions. The introduction of a flexible breakfast had proved to be successfull. The inspector observed breakfast being served and noticed that staff were not as rushed at trying to see to residents all at one time. This also allows for residents who wish to have a lie in bed the opportunity to do so. There was a choice of breakfast dishes available including cereals, toast or a cooked breakfast; a hot drink was served. The main meal of the day is served at lunchtime. Two choices were available including gammon, creamed or new potatoes and spouts or vegetable lasagne. The inspector noted that the pureed diet had the portions individually blended so that residents could see the different colours of the food and experience the different tastes and textures. A dessert of stewed apples with sultanas and cinnamon with ice cream or fruit was available. Staff were seen assisting residents who needed help in a discreet and sensitive manner. To assist a resident in making a choice of meal, one member of staff said to another, “Show both choices and explain what they are, let her pick what she wants”. The inspector noted the tables were nicely set and that there was appropriate aids for example plate guards if needed and suitably cutlery. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 15 An afternoon tea is served and residents were to be offered a choice of fruit juice, homemade leek and potato soup, shepherds pie or omelettes. Mid morning and afternoon drinks were served accompanied by a fruit platter. Suppers are available before residents retire and includes sandwiches, toast, milky drink or drink of their choice. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters can be assured that any concerns or complaints will be listened to, taken seriously and appropriate action taken. EVIDENCE: The home has a satisfactory complaints procedure in place for the recording of any complaints or concerns. There has been two minor concerns brought to the attention of the manager, these were suitably dealt with and information recorded. There have been no complaints made to the CSCI since the last inspection. Staff have completed training in the protection of vulnerable adults and the manager has confirmed that annual updates will be provided. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 17 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, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main, Westleigh Lodge is well maintained and provides residents with a comfortable and safe place to live at. EVIDENCE: From a tour of the premises, it was evident that some areas of the home had been decorated and a new carpet fitted on the first floor. Throughout the home the bedroom doors had been painted in bright colours and had numbers and doorknockers on them to assist residents in locating their own rooms. The bathroom doors had signage to indicate to residents that this was a bathroom, for example a sponge, back scrub and other prompts that you would find in a bathroom. Outside the dining room was a plaque with dishes on, plates and cups and saucers, again to prompt that this was the dining room. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 18 There are no locked doors to the communal areas and residents can move freely around. Bedrooms are not kept locked so that residents can return to their rooms if they wish. The bedrooms inspected were clean and tidy and most of them had been personalised with belongings, photographs and mementoes brought with them from home. The manager is aware that some resident’s rooms have little or no personal items especially if there is no next of kin; this is an area the manager intends to address. At the last inspection of 25 October 2006 a requirement was made about the poor condition of the corridor carpets on both floors. The carpets were dirty and were heavily stained and passed cleaning. The corridor carpet on the first floor had been replaced; the ground floor had not been replaced. An immediate requirement was made that the carpet has to be replaced within the timescale given. Both the inspector and staff agreed that the carpet was unsightly and the odour of urine that came from the carpet was not acceptable and was offensive for residents living at the home and relatives and other visitors on entering the home. If this is not addressed within the timescale of 31/01/08 the CSCI may consider enforcement action, as this is a repeated requirement. The manager is supposed to be having her own office, sharing with the administrator is not ideal as residents are constantly trying to gain access to the office and the telephone is ringing all the time. If the manager needed to speak with a member of staff or a relative in confidence this could be difficult and disruptive for the administrator who has to leave the office. There is a room that has had some work done to it for the manager to move into however for some reason this has been a slow process. The domestic staff work hard to keep the home clean and in the main free from offensive odours. The bathrooms were clean and tidy and no communal toiletries were seen. The outside of the home is well maintained, the garden area to the side of the home needs to be developed, when the better weather allows outside garden work. Systems are in place to control the risk of cross infection. Staff were seen wearing different protective clothing when carrying out different tasks and hand sanitizer was readily available. The laundry is sited on the second floor away form food preparation and food storage areas. Residents do not have access to the second floor. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and the skill mix of the staff was satisfactory ensuring the needs of the residents can be met. EVIDENCE: The rotas showed that there are sufficient staff on duty each day and through the night. This must be regularly reviewed to ensure that the changing needs of the residents can be met at all times. Domestic staff are employed in sufficient numbers to cater for the needs of the residents and to support care staff. Staff training is progressing well with 59 of staff having achieved NVQ level 2 in care, with another eight members of staff having enrolled for NVQ level 2. A full copy of each members of staff’s employment file is kept in the home in a secure location. Three staff files were inspected and contained, CRB disclosures , an application form, health questionnaire, two references, job description and other forms of identification. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 20 Several members of staff have worked at the home for some considerable time and this provides residents with consistent and reliable care. Staff appeared to work well together and morale appeared to be good. All new staff completes a thorough induction programme, evidence of this was on the most recently recruited member of staff’s file. There was evidence in files to indicate staff had received training in moving and handling, protection of vulnerable adults, basic food hygiene, fire training and dementia and managing challenging behaviour. The manager discussed with the inspector that a small number of staff are reluctant to attend training. If staff refuses to attend training they cannot be seen as competent to carry out their role and this could result in residents being placed at risk, for example using inappropriate moving and handling techniques. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff can be sure that their health, safety and welfare will be promoted and protected. EVIDENCE: Since the last inspection 25 October 2006 the manager has become more confident in her role and has developed her managerial skills. The home is running smoother and staff are more aware of their roles and responsibilities in the home. Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 22 The manager is committed to her own training as that of her staff and sees it as an essential element for delivering good quality of care for residents. The manager has a good awareness of the residents living at the home and operates an ‘open door’ policy so that she can be approached at any time by staff or relatives. Quality assurance systems are in place, audits are sent monthly to head office re falls, medication, accidents etc. The manager invites relatives to attend reviews either every three or six months. At the end of the inspection an immediate requirement was made regarding the monthly visits to the home that must be made by a member of senior management from Southern Cross. These visits had not been made in accordance with the regulation and were not available for inspection. This was an outstanding requirement from the last inspection of 15/05/06. If this is found to be outstanding again it may result in the CSCI having to take enforcement action. Some of the residents living at the home have small amounts of personal allowance money held by the home. It is the company policy that the home has an aggregate personal allowance account. The regional admin manager has confirmed, this account will pay interest to the residents and automatically apportion interest to each resident, this has not started yet but when it is up and running all residents will be back dated to the roll out. Balance sheets are kept on the homes computer of all accounts and transactions. Records kept and required by regulation were seen to be in good order and up to date, all records are kept securely as required. Equipment and systems used in the home are serviced and maintained, and records are kept. The following checks have taken place and certificates were readily available to verify that: Hoist serviced: 16/06/07 Lift and dumb waiter: 22/10/07 Gas: 15/02/07 Electrics: 07/04/03 Water testing: 19/05/07 Fire systems: 01/07 The home accident book was available for inspection and any accidents, incidents or injuries had been recorded and the CSCI informed as required. Westleigh Lodge DS0000005703.V345561.R01.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 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 x 3 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 23 (2)(d) Requirement You must, having regard to the size of the care home and the number and needs of the residents ensure that, all parts of the home are kept and clean and are reasonably decorated with specific regard given to the corridor carpets on both floors which are dirty and heavily stained. (The ground floor carpet has not been replaced and this is outstanding from the last inspection of 15/05/06 with a timescale given of 15/12/06. An immediate requirement was issued) Timescale for action 31/01/08 2 OP33 26 Monthly visits to the home from 02/11/07 a named person from Southern Cross Healthcare must be carried out and a written report produced. (This is outstanding from the last inspection on 15/05/06 with a timescale given for 07/07/07 and from the inspection of 01/11/07. An immediate requirement was issued). DS0000005703.V345561.R01.S.doc Version 5.2 Page 25 Westleigh Lodge RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP31 Good Practice Recommendations The registered manager should continue to work to complete the Registered Managers award. The registered person should give consideration to landscaping the grassed area to improve the outside space further. 6. OP19 Westleigh Lodge DS0000005703.V345561.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Lodge DS0000005703.V345561.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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