Inspection on 11/01/06 for Westley Court Nursing Home

This inspection was carried out on 11th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westley Court Nursing Home 11/06/08

Westley Court Nursing Home 24/01/07

Westley Court Nursing Home 14/07/05

Westley Court Nursing Home 22/11/04

Westley Court Nursing Home 27/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Westley Court Nursing Home Austcliffe Lane Cookley Kidderminster Worcestershire DY10 2RT Lead Inspector Andrew Spearing-Brown Draft Unannounced Inspection 11th January 2006 10:00 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 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 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. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westley Court Nursing Home Address Austcliffe Lane Cookley Kidderminster Worcestershire DY10 2RT 01562 852952 01562 851935 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) Alpha Health Care Limited Mrs Gillian Hall Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (5), Physical disability of places over 65 years of age (30), Terminally ill (3) Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That service users accommodated within the category of PD are aged 40 and above. The home may accommodate one named service user over 55 with a learning disability. 14th July 2005 Date of last inspection Brief Description of the Service: Westley Court is a modern, purpose built nursing home, which is situated, in an attractive rural setting adjoining the main Kidderminster to Wolverhampton Road. The home is registered to accommodate a maximum of 30 residents in single room provision, with en-suite facilities. The rooms are situated on the ground and first floor with a connecting lift. A communal lounge/dining room is available on the ground and first floor. Westley Court Nursing Home is part of a group of homes owned by Alpha Health Care Ltd. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a period of one day. One regulation inspector was present throughout while a second joined half way through making the visit last a total of 7 ¼ hours of inspectors time. Both inspectors were from the Worcester office of the Commission for Social Care Inspection (CSCI). The last inspection at Westley Court took place during July 2005 making this inspection the second statutory visit during the 2005 – 2006 inspection year. At the time of this inspection 29 residents were residing at the home with 1 vacancy on the nursing unit. Part of this inspection was to assess the progress made in relation to the requirements from previous inspections. A number of areas of serious concern were identified during the inspection. An immediate notice was issued at the time, which was followed up by a letter to the registered provider. Consultation with residents was very limited on this occasion. A greater emphasis on residents comments will therefore take place as part of future inspections. Some parts of the home were seen. These areas included communal areas as well as a representative number of bedrooms. The care records regarding a sample number of residents were viewed. Other documents seen during the inspection included medication records, staff rotas, staff files and training records. What the service does well: The home is modern and purpose built situated in a rural setting. Residents appeared well cared for. A representative sample of bedrooms were seen some of which were personalised by the resident residing within that room. All bedrooms are single with en-suite facilities provided. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 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. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 7 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 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 6 The availability of a statement of terms and conditions ensures that residents or their representatives are aware of their rights within the home. EVIDENCE: Neither the Statement of Purpose nor Service Users Guide were seen on this occasion and will therefore be reassessed as part of a forthcoming inspection. A small booklet was freely available. This booklet contains out of date information in that it states the home is ‘registered with the local Heath Authority and Social Services in Worcestershire.’ Since the introduction of the Care Standards Act and The Care Homes Regulations in April 2002 care homes have been registered with the National Care Standards Commission and then the Commission for Social Care Inspection. One of the photographs does not appear to be within the main body of the care home and could therefore by within the adjacent complex of retirement apartments. This booklet should be withdrawn forthwith. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 9 A copy of the homes Statement of Terms and Conditions was held on each residents file seen. Although these were not assessed in any detail to ensure that all areas of standard 2 were covered it was however noted that they contained details of bedroom numbers. Westley Court has a contract with the Primary care Placement Scheme, which enables 5 residents to be admitted to a designated rehabilitation unit. This unit, which is located on the first floor, offers rehabilitation on a short-term basis prior to being discharged home. The unit has a designated team of staff to care for residents, although the understanding is that these staff do provide care and support to residents on the nursing unit when time allows. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Care plans and risk assessments were insufficient and inconsistent in that they did not give the necessary detail regarding residents care needs to ensure that care staff are able to provide the level of input required. The management, recording and administration of medication were poor and need urgent and immediate attention to ensure that residents are not placed at a significant risk which could potentially affect their health and well-being. EVIDENCE: As part of this inspection a random number of care plans were viewed Care plans seen were poor in that they did not accurately reflect the current care needs of residents. Care plans contained global statements that were found to be similar on other residents care plans regarding the same care need such as anxiety. Care plans were not specific and were not person centred. Bathing records were not maintained and an example was seen whereby bathing was not cross-referenced to the care plan following a resident refusing personal care intervention. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 11 Terms used such as ‘ Care as plan’ or ‘ Uneventful day’ were recorded upon the daily records. The use of such terms did not specify the actual care provided especially when the care plans were identified as poor in the first place. Weight records seen were poorly maintained in that findings were not satisfactorily monitored or not suitably followed up. On one care plan dated 25th November 2005 it was cited that a resident was to be weight in one weeks time; it could not be evidenced that this had taken place. Sit on scales are available. Risk assessments were either inappropriate and insufficient in detail or not suitably reviewed in a number of areas. A consent form regarding the use of bed rails was not signed or dated; it was however confirmed by staff that bed rails were nevertheless in use. Wound care records were poor and failed to demonstrate the progress of the wound. Blood sugar monitoring was insufficient The home uses a monitored dosage system (MDS) as part of the inspection some the MDS cassettes were viewed as well as a high percentage of the current months medication administration record (MAR) sheets. In addition a small number of the previous months MAR sheets were also viewed as well as the contents of the trolleys. A number of errors and serious shortfalls were found and brought to the attention of the trained member of staff. With the exception of medication administered by the night staff none of the morning medication was signed as given on the morning of this inspection. As a result the nurse of duty would have to sign for all other medication retrospectively. This practice is dangerous and must cease with immediate effect. Gaps were noted on the MAR sheets on a number of occasions whereby neither a signature nor a code was entered to indication whether medication was administered or not. It was noted that the use of codes on some MAR sheets was incorrect in that a tick was used in place of an initial. On other occasions the code F was used, having used this code detail of why the code is used is required. No detail was recorded on a number of occasions regarding this code. The section at the top of each sheet headed ‘ Allergies’ was in some cases completed by hand; however others remained blank. Any known allergies must be recorded here. If no allergies are known then ‘none known’ must be recorded. Medication must be signed into the home in order that a full audit can take place. On a number of occasions this information was not suitably recorded. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 12 In addition it was noted that on some occasions two persons had not signed hand written amendments to the MAR sheets. Some medication is prescribed on a variable dose. The MAR sheets did not always demonstrate the actual dosage administered, therefore it would not be possible to carry out an audit of these drugs. Two MAR sheets stated o/s (out of stock). This is of concern, as the home should have suitable procedures in place to ensure that this does not happen. On one occasion the MAR sheet stated ‘o/s’ on the second day of the month, no medication was ordered that month. On another sheet ‘o/s’ was recorded on a couple of occasions, it was however discovered that medication was in stock and held within a stock cupboard. Correction fluid was used on one previous MAR sheet seen within a residents own file. Further concerns were raised upon brief inspections of both the ground floor and first floor medication trolleys. The majority of medication is held within a monitored dosage system (MDS) or blister packs. Some of the MDS’s had medication remaining within them these did not always cross reference correctly to the MAR sheets. A plastic container within the ground floor trolley was labelled analgesics (painkillers). This container contained a number of lose dispersible tables, these were unnamed and therefore the home could not demonstrate who they belonged to. It was concerning to discover that painkillers prescribed to a resident on the first floor were kept in the downstairs trolley. It appeared that this medication was being administered to other residents and not to the person to whom the drugs were prescribed. This is dangerous practice and prevents any drug audit taking place The controlled drugs cabinet was briefly viewed. The balance recorded within the controlled drugs book was checked against the actual drugs held in relation to one resident and found to be in order. The previous inspection report states that the dispensing pharmacy had visited the home during June 2005. The trained member of staff on duty was not aware of any subsequent visit and did not know the whereabouts of any reports. The homes medication policies and procedures were not viewed on this occasion. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 13 An immediate requirement notice was left in respect of the above serious concerns regarding the administration and recording of medication. Other areas regarding medication management will be assessed as part of a forthcoming inspection at Westley Court. Prior to issuing this report a pharmacy inspector from the CSCI has visited the home. A separate letter will be compiled in relation to that visit. The previous report highlighted concerns regarding the need to raise awareness within the home in relation to confidentiality. The concern was in relation to the storage of records and general communication within the home. Due to the location of the nursing station information may be shared in an area where others can hear, staff stated that they were aware of this matter and made efforts to ensure that other persons were not in hearing distance. Reference to the storage of documents is included later in this report under standard 37. It was noted that the toilet accessed from the downstairs lounge and at least one bathroom had either no lock fitted to the door or the lock was broken; this indicates a lack of awareness regarding the need to up hold residents privacy. The majority of residents remained within the privacy of their own rooms rather than accessing communal areas throughout most of the day. It was noted that residents appeared well cared for and well kept. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Westley Court. EVIDENCE: The previous inspection took place during a warm spell last summer; this inspection took place during the winter. Following the last inspection the registered persons were required to provide equipment such as additional parasols. Due to the time of year evidence of compliance would not be easily obtained; however a member of staff confirmed that items were obtained following the last inspection. The suitability of equipment will be assessed as part of a forthcoming inspection. The current days menu was displayed. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): There is a clear complaints procedure in place to assist in safeguarding the interests of residents. EVIDENCE: The homes complaints log was viewed. The last recorded complaint was taken on the day of the last inspection at Westley Court. A copy of the homes complaints procedure was on display. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 The general standard of the environment within the home is satisfactory providing a comfortable and homely place to live. Improvement in the cleanliness of both dining room floors was noted at the time of this visit. EVIDENCE: During this visit a partial tour of the home took place. The home is generally maintained to a good standard. Residents have access to communal space on both floors. The lounge / dining room on the ground floor was noted to be untidy in that food debris was on the floor throughout the inspection. The carpet in the dining room on the first floor was stained. It was of concern to note the number of bedroom doors wedged open – see standard 38. All the bedrooms are single and have en-suite facilities. Some bedrooms were personalised to make them look more homely. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 17 A downstairs bathroom is currently been converting into a shower room. Due to a lack of storage a bathroom on the first floor was used to store wheelchairs, walking frames and walking sticks. An outside door was held open, this door lead to a small enclosed courtyard. Smoking is permitted within the courtyard hence why the door was held open; this was however causing a cold draught. The laundry is off this courtyard. At one point the door to the laundry was open while the laundry was unsupervised thus potentially allowing access to unauthorised persons. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Staffing levels remain the same as the previous inspection. Alpha Health Care continue to review staffing levels to ensure that care needs can be met. Training records continue to be out of date and therefore unable to demonstrate that staff receive the necessary knowledge to ensure the safety of residents and themselves. Recruitment practices ensure that suitable procedures are in place which safeguard residents. EVIDENCE: The nursing staff on duty confirmed that the current weeks rota showed staffing levels to be the same as highlighted within the previous inspection report. On the day of this inspection, the home was staffed by one trained nurse and 6 carers in the morning and 5 carers in the afternoon /evening. 2 of these carers staff the rehabilitation unit at all times during the day/evening. At the time of the last inspection concern was raised regarding staffing levels/ratios and deployment of staff. Staffing levels remain the same however Alpha Heath Care assure the CSCI that the current levels are sufficient to meet the care needs of residents residing at Westley Court and that additional resources are available when necessary. As registered providers Alpha Heath Care need to ensure that continual reviewing of staffing levels are in place. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 19 Other staff including floor domestics, kitchen domestics, a laundry assistant and a cook were also on duty on the morning of this inspection. As part of previous inspection staff training records seen indicated that some staff had not received essential training since their employment at the home. At the time of that inspection the registered manager said training had been given but records had not been updated. Training records were also seen as part of this inspection. As previously noted a number of shortfalls were apparent. In consultation with staff it would appear that as before training records were not up to date. As records were poorly maintained it was not possible to undertake an accurate audit of training. The files of two recently appointed members of staff were viewed. These contained documents such as written references. The nurse on duty confirmed that no new employee would be permitted to commence work at the home prior to the arrival of a POVA first check. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36, 37 and 38 Shortfalls were identified in relation to quality assurance and staff supervision both of which can assist in the promotion of good practice and safeguarding vulnerable persons. Serious shortfalls in health and safety especially the practice of wedging open fire doors can potentially leave residents at risk. EVIDENCE: The registered manager was taking annual leave on the day of this unannounced inspection. A file containing information following a residents survey during 2004 was briefly seen; no up to date information was known to exist. It was stated that Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 21 no recent staff or resident meetings had taken place during which quality assurance or monitoring could of taken place. Although records were not sought staff confirmed that supervision as described under standard 36 of the National Minimum Standards – Older People is not taking place. The previous inspection report highlighted the need to increase awareness within the home in relation to the storage of records. Care plans were held within a filing cabinet although this was unlocked. Other documents were left unattended on the nursing station and therefore could potentially be accessed by unauthorised persons. The inspection reported dated 22nd November 2004 stated ‘a number of fire doors were noted to be wedged open by a combination of wedges, despite written guidance from the fire safety officer earlier this year (2004)’. The previous inspection was undertaken on 14th July 2005 the report following this inspection also highlighted the wedging open of fire doors and an immediate requirement notice was issued. The action plan written on behalf of the registered provider stated that the manager would continue ‘to encourage service users not to wedge doors open . .’ This suggests that it is residents who are wedging doors open when they are clearly wedged open by staff members. Although it was noted that a number of doors have a devise fitted which activates the door closure on sounding the fire alarm a signification number of bedroom doors have none fitted. A minimum of 14 bedroom doors were wedged open. The wedging opening of fire doors is a dangerous practice, as it would prevent fire doors closing in the event of the fire alarm sounding. The registered provider was required to take immediate action by means of suitable measures to afford residents easy access around the home without compromising health and safety. Prior to completing this report the registered provider has undertaken to fit suitable devises as described in order to replace all door wedges. A door to a storeroom behind the nursing station was held open by the means of an oxygen cylinder. Records regarding the testing of the fire alarm were held at the main reception desk. These were not fully audited as they also included information upon the retirement apartments. No records were available regarding the monthly visual checking of fire fighting equipment. Fire signage regarding fire fighting equipment and break glass points was lacking. Training records were poorly maintained therefore it was not possible to fully establish whether all staff have received the required fire training; however from discussions with staff it was evident that there were shortfalls in training undertaken. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 22 Accident records viewed were not in sequential order; an audit of accidents was not available. No protocol upon the action to be taken following a head injury was available. Temperature records maintained by the kitchen were viewed these were in order. The kitchen itself was not viewed and a cleaning schedule was not sought. The existence of a cleaning schedule for other areas of the home including kitchenettes and toilets was unknown. No temperature records are maintained in relation to the fridges within the kitchenettes. The fridge in the first floor kitchenette contained pate, which can be a high-risk food. Carers stated that residents families occasional bring items of food in; these items do however need to be monitored and dated. No hand washing facilities were available within the kitchenettes. Two cupboards containing hot water tanks were unlocked therefore affording residents or unauthorised person access to potentially hot pipes. The door to the boiler room was locked, as were doors to cleaning cupboards. Temperature records of bath and shower water are not maintained and therefore it was not possible to assess safe bathing procedures as taking place. Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 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 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 2 1 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 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 OP1 Regulation 4 (1) Requirement The homes Statement of Purpose must detail: Up to date information of the number , relevant qualifications and experience of staff working in the home. Up to date information relating to the Commission for Social Care Inspection. (Requirement from a previous inspection 22/11/04 not assessed on this ocassion. Previous timescale remains in place) 2. OP1 5 (1) The Service User Guide must 01/09/05 include: Up to date information regarding terms and conditions in respect of accommodation to be provided. A copy of most recent inspection report . (Requirement from a previous inspection 22/11/04 not assessed on this ocassion. Previous timescale remains in place) DS0000004154.V273751.R02.S.doc Version 5.0 Page 25 Timescale for action 01/09/05 Westley Court Nursing Home 3. OP7OP8 15 (1) Each resident must have care 22/02/06 plans in place, which accurately reflect their current physical needs and contains accuarte details of the care and support to be provided by staff to meet those needs. (Previous requirement of immediate and on going set on 14/07/05 not met. This requirement must be fully met in 6 weeks starting with residents at greatest risk) 4. OP7OP8OP 37 15 (1) Individual records must be kept in relation to any wound, which includes details of regular assessments, current treatment and reviews. (Previous requirement of immediate and on going set on 14/07/05 not met. This requirement must be met immediately) 11/01/06 5. OP7OP8 15 (1) A care plan must be initiated whenever care needs are identified. (Previous requirement 22/11/04 and 14/07/05 not met. This requirement must be met immediately) 11/01/06 6. OP7 15 (1) Care plans must be put in place for all residents with identified emotional, social and psychological needs. Plans must demonstrate how these needs are to be supported by staff. DS0000004154.V273751.R02.S.doc 22/02/06 Westley Court Nursing Home Version 5.0 Page 26 (Previous requirement 22/11/04 and 14/07/05 not met. This requirement must be fully met in 6 weeks starting with residents at greatest risk) 7. OP9 13 (2) Any written additions or amendments to the medication administration records must be dated, checked, and signed by two staff. (Previous requirement 14/07/05 not met. This requirement must be met with immediate and on going effect) 11/01/06 8. OP9 13 (2) Medication Administration Record 11/01/06 (MAR) sheets must be completed adequately and at the time of administration. The correct codes as listed upon the MAR sheets must be sed in the event of medication not given. 11/01/06 9. OP9 13 (2) 10. OP9 13 (2) Medication Administration Record 11/01/06 (MAR) sheets must show all known allergies. In the event of ‘none known’ the MAR sheet must reflect this information. All medication received into the care home must be booked in. Prescribed medication must not be used for other persons. When a variable dosages is prescribed the actual dose given must be recorded. 11/01/06 11/01/06 11/01/06 11. 12. 13. OP9 OP9 OP9 13 (2) 13 (2) 13 (2) Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 27 14. OP9 13 (2) Suitable procedure must be in place to ensure that prescribed medication does not run out. Arrangements must be made where needs identified to enable residents to engage in local, social and community activities. (Requirement not assessed on this ocassion. Previous timescale remains in place) 11/01/06 15. OP12 16 (2) (m) 14/07/05 16. OP19OP26 23 Any soiled or stained carpets must be cleaned or replaced as necessary. (Previous requirement 22.11.04 and 01.10.05 met in part only. Extended timescale given) 31/03/06 17. OP22 23 Appropriate storage must be available for equipment, which avoids the use of communal areas and bathrooms. (Previous requirement 01.10.05 not met. Extended timescale given) 31/03/06 18. OP26OP38 13 (3) All staff must adhere to the homes policies and procedures in relation to infection control measures, and appropriate information must be passed on to all staff as necessary to ensure controls are maintained. (Requirement not assessed on this ocassion. Previous timescale remains in place) 14/07/05 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 28 19. OP26OP30 13 Cleaning materials within the laundry must not be accessible to unauthorised persons. 11/01/06 20. OP30 18 (1) (c) (i) Induction records must be signed and dated by the relevant trainer , to demonstrate satisfactory completion of any training . (Requirement from previous inspection 22.11.04 not inspected as part of this inspection. The previous timescale remains in place) 14/07/05 21. OP30OP38 18 (1) Staff training records must be mainatined and up to date showing all training undertaken. Provide and up date a quality assurance programme that enables staff,service users and their representatives to directly influence the service provided. (Requirement from previous inspection 22.11.04 not met. Extended timescale given) 28/02/06 22. OP33 24 (1) 31/03/06 23. OP36 18 (1) All care staff must formal supervision at least six times a year. Written records must be kept of all supervision that takes place. (Requirement from previous inspection 22.11.04 and 14.07.05 not met. Extended timescale given) 28/02/06 24. OP37 17 All personal information relating to residents must be stored securely. DS0000004154.V273751.R02.S.doc 07/02/06 Westley Court Nursing Home Version 5.0 Page 29 25. OP38 23 (4) (c) (Requirement from previous inspection 14.07.05 not met. Extended timescale given.) Fire doors must never be held 11/01/06 open by means which have not been appproved by the fire officer. If a fire door needs to be held open for health and safety reasons, a solution must be provided which is approved by all relevant authorities. (Previous requirements 27.05.04 22.11.04 and 14.07.05 not yet met in full. This must be met without further delay ) 26. OP38 16 Accurate written records must be 07/02/06 kept of all food temperatures and cleaning schedules adhered to . (Previous requirement 14.07.05 not fully met – extended timescale given) 27. OP38 23 The required fire signage must be in place throughout the home. (Previous requirement 14.07.05 not fully met – extended timescale given) Fire records including those regarding the visual checking of fire fighting equipment must be maintained as required by Hereford and Worcester Fire Authority. Hand washing procedures must be reviewed within the kitchenettes in line with food hygiene procedures. The doors on cupboards housing hot water tanks must be kept locked to prevent unauthorised DS0000004154.V273751.R02.S.doc 07/02/06 28. OP38 23 11/01/06 29. OP38 16 (2) (j) 28/02/06 30. OP38 13 11/01/06 Westley Court Nursing Home Version 5.0 Page 30 access. 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 OP1 OP7 Good Practice Recommendations The brochure available within the entrance hall should be withdrawn, as it no longer contains accurate information. Look at opportunities to encourage more involvement from residents in their individual care planning. (Previous recommendation 14.07.05) Consultation should take place with residents to establish any preferences for outings and excursions . In the event preferences are identified, opportunities should be made available and appropriate supervision provided. (Previous recommendation 22.11.04 and 14.07.05) A protocol regarding the action to be taken following a head injury should be developed. 3. OP12 4. OP38 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Westley Court Nursing Home DS0000004154.V273751.R02.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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