Inspection on 26/06/08 for Westleigh Lodge

This inspection was carried out on 26th June 2008.

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

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

Other inspections for this house

Westleigh Lodge 17/11/08

Westleigh Lodge 01/11/07

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Westleigh Lodge Nel Pan Lane Leigh Lancashire WN7 5JT Lead Inspector Judith Stanley & Avril Frankl (Pharmacist Inspector) Unannounced Inspection 26th June 2008 09:00 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.V366365.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.V366365.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.V366365.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. 1st November 2007 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 are situated 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 and tuck shop. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use the service experience poor quality outcomes. This inspection included a site visit and was unannounced and was conducted over one day by two inspectors, one being the pharmacist inspector. The inspection started at 09:00 am and was completed by 16:00 pm. Part of the time was spent in the office looking at information the home needs to keep to ensure that it is being properly run. This included four resident’s files (care plans) some staff files, staff training, resident’s monies, medication and maintenance and servicing of equipment. Prior to the inspection the manager was sent an Annual Quality Assurance Assessment form (AQAA) to complete. This information tell us what the home does well at, how they meet the National Minimum Standards (NMS), and in what areas they need to develop and improve. To find more out about the home we sent comment cards to residents, relatives and staff. To date no comment cards had been returned. Two visitors were spoken with and both were satisfied with the care their relatives received. Information on the AQAA indicated there had been no complaints made to the manager of the home since the last inspection and no complaints had been made to the CSCI. There had been two safeguarding referrals made to the adult protection team. What the service does well: The home offers different communal areas for residents to sit and relax in. There are no restrictions as to when people can visit their relatives. Bedrooms are of a good size and were clean, tidy and comfortable. The activities coordinator plans and delivers a varied range of activities. The home offers residents a well-balanced and varied diet. Staff at the home offers good support to residents families. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Ensure that residents are appropriately groomed. Some ladies looked dishevelled, their hair appeared not to have been brushed since getting out of bed. Most of the gentleman had not been shaved and it was noted that one gentleman’s toenails were dirty and needed cutting. The smell of urine masked by air fresheners on entering the home must be eradicated. There is obviously a problem in that area, the rest of the home did not suffer from malodour. The chairs in the ground floor lounge must be cleaned; these were heavily stained and black. The inspector showed the manager several wheelchairs on the ground floor, which were encrusted with dried food. Medicines must be given to residents exactly as prescribed to make sure their health is not placed at risk. Records regarding all areas of medicines handling must be clear and accurate and must be able to show exactly what medicines have been given to residents. The records must also be able to show that all medicines can be accounted for. Steps must be taken to ensure that all medicines are stored at appropriate temperatures. The hot trolley must be fixed or a new one purchased. Residents on the first floor were packed into the dining room and there were not enough staff to assist at least eleven people that needed help, this resulted in resident’s meals going cold. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 7 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.V366365.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.V366365.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 Westleigh Lodge does not provide an intermediate care service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Contracts were not in place for all residents, therefore people could not be clear about the terms and conditions of the home. EVIDENCE: We selected four residents to case track throughout the inspection. On checking to see if the four residents had been provided with a contract/statement of terms and conditions at the point of moving in to the home, it was found that only one resident had a contract in place. In three care plans there was evidence of a pre admission assessment, one file did not have an assessment included. The assessment ensures that the resident’ health and personal care and social care needs could be met. On Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 10 admission to the home a more detailed dementia assessment is carried out to see at what stage the dementia is at, what the residents capabilities are, what skills the residents has retained, and the levels of communication, continence, sleep patterns, mobility and diet. Staff training in caring for people with dementia is ongoing. All staff are to attend the Yesterday, Today and Tomorrow training which will also assist staff to understand the importance of meeting the diverse needs of individual residents. Westleigh Lodge DS0000005703.V366365.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 poor This judgement has been made using available evidence including a visit to this service. There were a number of weaknesses in the record keeping which made it difficult to tell if some medicines, creams and food thickeners had been given properly or if they could be accounted for. Poor record keeping can lead to mistakes in medicines administration and residents’ health could be placed at risk. EVIDENCE: We continued to use the same four care plans. There was a lot of information in the care plans that provided staff with information about the care each resident required. Some of the recording sheets are duplicated, which makes the information difficult to find, for example there are two charts for recording residents weights on, so it can appear that if you look at one chart it may not be filled in but the other is. Some residents had not been weighed as required. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 12 Two residents that should be weighed on a weekly basis had not been. Other information includes, personal care, physical well-being, mental state, cognition, diet, sight, hearing, oral and foot care, continence, sleeping, social interest, medication, skin tact etc. A social profile was seen which informs staff about the residents past life experiences such as where they were born, school days, first job, friends and family, places of interests and holidays and likes and dislikes. This information is important for staff to enable them to talk with the residents about familiar things as most of the residents in the home have communication and memory problems. The care plans had been reviewed monthly as required and the manager holds three or six monthly residents reviews, to which family are invited to attend. The manager also stays late at the home one night a week so that family have the chance to speak with her and discuss any issues. Risk assessments were seen in the care plans, for example risk of falls and mobility, nutrition (screening tools) pressure care and moving and handling. There was evidence to show that outside agencies such as the tissue viability nurse, the dietician, doctors and the chiropodist are contacted and visit as necessary. It was noted that for some residents personal appearance could be improved. Several ladies appeared not to have had they hair brushed on getting up. Most of the gentlemen had not been shaved and one gentleman was being shaved in the lounge. There was nothing recorded that staff had tried to shave the men but they had refused. This is part of personal care and should be addressed as staff assists people in getting up in the morning. One gentleman was walking round with no socks or shoes on, this resident’s feet and toenails were seen to require attention. The inspector observed the way the staff tried to maintain residents dignity, as this can sometimes be difficult in this type of care setting. It was noted that one resident who was seen removing clothing several times was sat in corridor on the floor, a care assistant promptly went for a blanket to cover the resident, then went to look for the missing trousers. The manner in which the staff spoke with residents was friendly and respectful. During this inspection the pharmacist inspector looked at medicines, records regarding medication and care notes for ten residents. This was to make sure that improvements in medicines handling found at the last inspection had been sustained and to make sure residents were being given their medicines safely. We found that medicines were not always administered to residents properly for a variety of reasons. Some medicines, for half the residents whose files we Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 13 looked at, were not available in the home either because they had run out or because they had not arrived in time to ensure continuity of treatment. When medicines are not given as prescribed residents’ health could be put at risk. It took nurses a long time to administer medicines in the morning this meant that some residents were given medicines, which should be taken with or shortly after food, a long time after they had eaten. When medicines are not given at the correct times they may not work properly or they may cause harm to the residents’ health. Some of the record keeping about medicines was good. The records of receipt and disposal were clear. Nurses recorded a lot of information on the back of the Medication Administration Record sheets (MARs), which clearly showed what dose of medicines, had been given or why medicines had not been taken. However there were still a number of weaknesses in the record keeping which made it difficult to tell if some medicines, creams and food thickeners had been given properly or if they could be accounted for. It is important to be able to track all medicines to make sure they are not mishandled. Poor record keeping can lead to mistakes in medicines administration and residents’ health could be placed at risk. Medicines are stored in a medication room on each floor entry to these rooms is by a code lock and all staff have access to the rooms. Although most medicines are safely locked away unwanted medicines are not. It is important that all medicines are stored securely to make sure they are not mishandled. Creams were kept in residents’ bedrooms in unlocked drawers. There were no risk assessments on file to show that it was safe to keep creams in individuals’ rooms. People may be at risk if they have access to medicines, which should be locked securely away. We also found creams in bedrooms, which should have been kept in the fridge. Medicines, which are not stored at the correct temperatures, may become ineffective and cause harm to residents’ health. Controlled drugs were stored properly and records regarding controlled drugs were accurate and could show that these drugs could all be accounted for. We saw that nurses did not always follow the home’s medication policies and procedures especially with regard to the disposal of medication after a person had passed away. It is important to follow policies in order to protect residents from harm. The manager did monthly audits of medication to make sure that medicines were handled safely and residents were given their medicines properly. When concerns were found she discussed them with the nurses so they could improve areas of weakness. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a wide range of activities to suit the resident’s capacities. EVIDENCE: The home has an activities coordinator who is enthusiastic about her role and enjoys her work. Activities include trips out to the local pub, shopping, one resident had chosen everything he wanted in his room and bought a new television, one to one chats, gardening crafts, and beauty treatments such as manicures and pedicures. The introduction of the tuck shop has proved to be a success and some residents eagerly a wait for the trolley to come round. One resident wanted to attend church on Sunday morning and care staff now escort this resident to church to facilitate their wishes. Visitors to the home are made welcome, there are no restrictions as to when people can visit and how long they stay. Some visitors come at lunchtime and help in feeding their relative. There are facilities for visitors to make refreshments if required. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 15 It is noted that most of the residents have communication and memory difficulties so were unable to confirm they were able to exercise choice. Nevertheless observation of practices indicated residents could make some choices for example in regard to meals and where they spent their day. The menus are planned by head office, although changes are made if required. The home offers a flexible breakfast time, to allow resident to get up when they are ready. A choice of hot and cold dishes was available. Lunch is the main meal of the day and on the day of the inspection there was a choice of chicken casserole with potatoes and vegetables or mushroom tagliatelle, followed by dessert. Lunch as a rule is served over two sittings so that the dining rooms are less cramped and staff are able to assist residents that need help feeding. This system was working in the ground floor dining room, however the hot trolley in the upstairs dining room was broken. Staff confirmed it had been broken for some time. This meant that more than twenty residents had to use the same dining room all at the same time. There is not enough space for all the residents some in wheelchairs and staff to sit comfortable in the dining room. Staff confirmed that at least eleven residents needed feeding. Although staff were doing their best, it was noted that residents were not being assisted as required and that their food was cold. The urgency of getting the hot trolley fixed or purchasing another was discussed with the manager A lighter meal is served at teatime; choices are available. Suppers are served before residents retire, choices are available are sandwiches, toast, milk drinks or tea or coffee. Hot and cold drinks and snacks were served throughout the day. Westleigh Lodge DS0000005703.V366365.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. Effective systems are in place for the reporting of any complaints. Policies and procedures and training were in place to safeguard residents from abuse or harm. EVIDENCE: A complaints procedure is in place, which gives details of how to complain. Most residents living at the home would find it difficult to communicate if they were not happy about something and rely on their relatives to act on their behalf. Information on the AQAA shows that there had been no complaints made to the manager of the home and no complaints had been made to CSCI since the last inspection. Staff had received training in the protection of vulnerable adults and a copy of the local councils’ adult safeguarding procedure is available to staff. Since the last inspection there have been two safeguarding referrals made and these had been appropriately dealt with. Westleigh Lodge DS0000005703.V366365.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 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main the home was warm and comfortable, however there were some areas that require attention to ensure that residents live in clean and pleasant surroundings. EVIDENCE: On entering the home the smell of urine masked by heavily scented air fresheners was offensive. It was evident that there is a problem in that area, as the rest of the home did not suffer from malodour. This was discussed with the manager and the malodour must be eradicated. From tour of the premises there was evidence of some refurbishment, with some new carpets and flooring and one resident had been out shopping and Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 18 had selected all the furnishings and fittings for his room. The corridors were bright and all doors leading into resident’s rooms are painted a different colour with the room number, name and doorknocker fitted. There are symbols and signage around the home to help prompt residents when moving around the home. The chairs in the downstairs lounge require deep clean or replacing as these were seen to be heavily marked and stained. The inspector noted and showed the manager several wheelchairs that were covered in dried on food. These had been taken back to people’s rooms after meals and had not been cleaned for some time. The bathrooms were clean and tidy, however it was noted in one bathroom (5) that block soap had been left in the bathroom. This poses a risk to people with dementia as it could be eaten and cause a severe reaction. Resident’s bedrooms were clean and tidy and most residents had brought with them their own personal possessions, photographs and mementoes. The outside grounds and gardens were neat and tidy. On the day of the inspection it was raining very hard and it was noted that the downspout outside the window of room 22 was overflowing and making a loud noise, this requires attention as it could be distracting for the resident trying to sleep or relax in that room. Systems were in place to control the risk of cross infection. Staff were seen wearing different protective clothing when carrying out different tasks. The laundry is on the top floor where residents do not have access to and is a way from food preparation and food storage areas. Westleigh Lodge DS0000005703.V366365.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 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory ensuring consistency of care for people living at the home. The residents were cared for by staff that was safely recruited following the necessary checks. EVIDENCE: The staff rotas showed that there are sufficient numbers of staff on duty each day and through the night. The ratios of nurses and care staff to residents takes into account the needs of the residents. Staffing levels were discussed with the manager who felt the care staffing levels were right at the time of the inspection, however the manager confirmed that home would benefit from a domestic covering a ‘twilight shift’. On each floor there is nurse responsible for the shift and the running of the floor. There were some serious issues around medication, which only the nurses are allowed to dispense. This was not just from the medication round observed on the day of the inspection, this poor practice applies to all nursing staff who have a responsibility to record, check and administer medicines correctly to ensure the safety and well being of the residents. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 20 Training in NVQs for care staff is progressing well, with over 50 of staff having achieved a qualification. Other training undertaken included: protection of vulnerable adults, dementia care, infection control, moving and handling etc. Care staff were observed carrying out their roles efficiently and it was apparent they had a good understanding of the needs of the residents they were caring for and they appeared happy in their work. We looked at three staff employment files and these were seen to be complete and up to date and included an application form, written references, medical questionnaire, Criminal Records Bureau disclosure and other forms of identification. Westleigh Lodge DS0000005703.V366365.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager has the qualifications and experience to manage the home, and tries to ensure the best outcomes for the people living there. EVIDENCE: The manager has a nursing qualification and has a number of years experience in working with elderly people with a mental illness. The way in which the home runs is open and transparent. The manager operates an ‘open door’ policy so that she may be approached at any time. This was observed on the day of the inspection. One evening a week the Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 22 manager stays late to give relatives who cannot visit during the day the chance to meet up with her and discuss any issues. At the last inspection it was discussed that the manager needs her own office. This was in progress at the last inspection and is still not fully operational, as the computer is not working. The inspectors felt that the manager is not fully supported by some of her staff and still does tasks that should be delegated to others, for example we asked for one care plan in particular, no one could find it, the manager went looking for it and found it. The nurse in charge of the shift should be aware of where the care plan was and been able to find it immediately. The manager should be able to have confidence in the ability of the nurses that they are giving medication properly and the errors should have been brought to her attention by some one, and in the absence of the manager that the home could be run by a person capable to do so. The manager needs to take a firmer stance with some staff to ensure to the home is running in the best interests of the residents. Quality assurance system are in place, this include regular audits, on falls, medication, accidents etc. Staff and relatives meetings are held and the home has satisfaction questionnaires. Monthly visits from senior management are now taking place as required and a copy of the report was available for inspection. Some residents hand over small amounts of money to the manager for safekeeping. It is the company policy that the home has an aggregate personal allowance account. It is confirmed this account will pay interest to the residents and automatically apportion interest to their account. Health and safety policies and procedures were in place. The staff team have completed health and safety training. Accidents had been recorded appropriately and the CSCI informed as necessary. Information provided on the AQAA indicted that all the necessary servicing of equipment and maintenance checks had been carried out and certificates at the home were valid and up to date. Westleigh Lodge DS0000005703.V366365.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 1 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 (1)(b) Requirement All residents must have a written contact/terms and conditions regardless of how their care is purchased. Residents are to be assisted with all aspects of personal care and grooming. All medicines must be given as prescribed and an adequate supply of medication must be available to ensure that this is possible All records about medicines must be clear and accurate and show clearly that medicines have been given properly and can all be accounted for All medicines must be stored safely and securely to make sure that they are not mishandled. They must also be stored at the correct temperatures to ensure they work properly. 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 with specific regard to the DS0000005703.V366365.R01.S.doc Timescale for action 08/08/08 2. 3. OP7 OP9 12(1)(a) 13(2) 27/06/08 27/06/08 4. OP9 13(2) 27/06/08 5. OP9 13(2) 27/06/08 6. OP19 23 (2)(d) 08/08/08 Westleigh Lodge Version 5.2 Page 25 7. OP30 18 (1)(a) 8. OP31 24 (1) cleaning of the chairs and the offensive smell on entering the home. You must ensure that all staff are competent to carry out their role with specific regard to medication to ensure the health and welfare of the residents. You must ensure a system for maintaining the quality of the services provided and in the manner in which the services are to be provided. 08/08/08 08/08/08 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 Refer to Standard OP15 OP38 Good Practice Recommendations The hot trolley must be repaired or a new one purchased to ensure the food is served at the correct temperature. That the bathrooms do not have any block soap on show. Westleigh Lodge DS0000005703.V366365.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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.V366365.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. 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