Inspection on 15/08/07 for Westmead

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Westmead 05/08/09

Westmead 21/11/06

Westmead 20/12/05

Westmead 02/08/05

Westmead 24/03/05

Westmead 02/09/04

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 Westmead Westmead Close Off Ledwych Road Droitwich Spa Worcestershire WR9 9LG Lead Inspector Yvonne South Key Unannounced Inspection 15th August 2007 08:15a 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 Westmead DS0000018696.V342496.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. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmead Address Westmead Close Off Ledwych Road Droitwich Spa Worcestershire WR9 9LG 01905 778353 01905 776376 westmead@heart-of-england.co.uk www.heart-of-england.co.uk Heart of England Housing and Care Limited 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) Mrs Sueanna Elizabeth Stokes Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (35), Physical disability over 65 years of age (35) Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user category LD (E) is in respect of a named person only. Date of last inspection 21st November 2006 Brief Description of the Service: Westmead is a purpose built home offering a residential care service to a maximum of 35 people of either sex, over the age of 65 years. Two places are reserved for people who require respite care only. The home offers permanent residential care to older people who have care needs associated with physical disabilities and/or dementia illnesses. The home provides a safe, homely environment for people who are no longer able to cope in the community, and enables them to lead a full and active life within a risk management framework. There are 33 single bedrooms and 2 double rooms in the two-storey building, and a range of communal lounges, a dining room and a spacious, level, and accessible garden. A shaft lift facilitates movement between floors. Handrails are appropriately placed within the home and in the gardens. Special equipment is provided, for example to assist with bathing, mobility and lifting. The home is situated in a small housing estate on the outskirts of Droitwich Spa and public transport facilities are within reach. Heart of England Housing and Care Ltd own the home and the registered manager is Mrs Sueanna Stokes. It was stated on 15.08.07 that the current fees were between £1540 and £1580 per month. Additional charges were made for private purchases such as hairdressing services, chiropody, newspapers and magazines, opticians and dry cleaning. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social Care Inspection (CSCI) since 21.11.06 and the information obtained during fieldwork on 15.08.07. The fieldwork extended over eight and a half hours during which the inspector spoke to seven residents, a relative and five staff. The registered manager was on annual leave, therefore she was assisted by the home services manager, two senior lead carers and a lead carer. Three residents demonstrating a range of different needs were case tracked. Their care was assessed and their documents were inspected. A partial tour of the premises was undertaken. Prior to the fieldwork the CSCI sent questionnaires to ten residents, their relatives and their GPs. These sought opinions on the quality of the service provided. Five responses were received from residents, five from relatives and three were received from GPs. Also prior to the fieldwork an Annual Quality Assurance Assessment (AQAA) document was sent to the registered persons. This was completed on 29.06.07 and returned to the CSCI. This document sought the registered manager’s opinion of the service provided, and data concerning the home. This was an unannounced key inspection, which focused on the key National Minimum Standards. What the service does well: The home provides a warm welcome for everyone who calls and supports prospective residents to ensure they make the best decision for themselves regarding admission to the home. The home is clean, comfortable, well decorated and maintained. Residents are able to bring personal possessions to personalise their bedrooms. Communal lounges, dining rooms, toilets and bathrooms are well equipped to meet the needs of people who appreciate comfort and have difficulties with mobility. A range of in-house and community activities are arranged and people can choose whether to participate or follow their own interests. Faiths and cultures are respected and support is given where required to maintain individual commitments. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 6 The home has excellent links and working relationships with health care professionals and the residents receive the individual personal and health care they need. A choice of appetising meals is offered each day and the residents say the food is very good. Staff are well recruited and trained so they can provide the special care each person needs in a kind, competent and sensitive manner. The home is well managed and health and safety is constantly monitored. Systems are in place to keep people safe. 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. The summary of this inspection report can be made available in other formats on request. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 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 Westmead DS0000018696.V342496.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 was not assessed, as this service is not provided by this home. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information and support is available to assist people in making a decision regarding their admission to the home. All prospective new residents have their needs assessed before they are offered a place so that the home is sure they can provide the appropriate care. EVIDENCE: Copies of the Statement of Purpose and Service Uses’ Guide were readily available in the foyer of the home with copies of the home’s brochure and other useful information. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 9 The manager said in the AQAA that the Statement of Purpose, Service Users’ Guide and welcome pack included a checklist that guided prospective residents on how to look for a home, and a blank Heart of England contract. People were offered a tour of the home and opportunities for a trial stay. Residents said in the questionnaire responses that they had received sufficient information to assist them in making a decision and they had received a contract. Communication with the home confirmed that the home was able to meet the needs of those who moved in, and when they were no longer able to do so they helped to support residents through the selection and move to more suitable accommodation and care. Three care records were assessed that demonstrated that appropriate assessments had been undertaken and sufficient information gathered on which to base an initial care plan. The format of the admission document needed to be amended to include personal hygiene and physical well being. However the inspector was informed that this was currently under review. Residents told the inspector that they were well cared for and their needs were being met. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have access to the information and guidance they need and residents receive the support and assistance they require with their personal and health care. Medication is managed safely so that residents receive their drugs as prescribed. Residents receive the care they need in the manner they wish at the end of their life. EVIDENCE: The manager stated in the AQAA that there were person centred plans that had involved residents, and relatives where appropriate, in their compilation. Care was reviewed and residents had access to and positive relationships with health care professionals. Medication was reviewed and staff received training Risk assessments were undertaken and plans drawn up when necessary. Quality was monitored. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 11 Residents said in the questionnaire responses that they received the care and support that they needed. All except one person said that staff listened and acted on what they said and they received the medical support that they needed. A resident commented in the questionnaire; ‘I think at times staff give me excuses and don’t act on what I am actually telling them. I have problems that recur and the doctor is only called when the staff feel there is a need. This has meant that I have not received medication soon, enough which has resulted in the infection taking longer to clear. At times I have been in severe discomfort. I feel there is a need for a trained nurse to be on site for at least part of the day.’ One relative said; ‘So many residents have medical/mental conditions I do feel there is a need for a fully trained nurse to work at the home for a few hours each day. It would mean there would not be the need for a doctor to call and some concerns residents have could be sorted out far more quickly’. Other relatives said; ‘When I have needed to speak to a member of staff about my mother I have always been seen promptly and in a private room’. ‘My mother was very happy at Westmead getting all the help she needed during the day. There were a few issues about the help at night but I believe these were addressed by the manager to the best of her ability’. ‘A most prompt and caring approach when my mother had to be admitted to hospital’. Questionnaires returned by three GPs stated that there was good communication between the home and themselves. There was always a senior member of staff on duty that they could consult with and the staff demonstrated a clear understanding of the care needs of the residents. The home was aware when they were no longer able to meet the needs of a resident and acted appropriately at these times. As Westmead is a residential home not a nursing home trained nurses are not employed. People who need a nurse and nursing care beyond that which can be provided by the GP and district nurse service are transferred to an appropriate nursing home or hospital. A resident told the inspector that doctors and district nurses always visited when they were needed and the care records confirmed this. Assessments, risk assessments and care plans were detailed and informative. They were continuously evaluated and regularly reviewed. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 12 A few dates and signatures were missing and some topical medications (creams) were not identified. Some care plans were limited and lacked individuality but the general standard was good. Although communication between the home and relatives was good there continued to be very little evidence that residents or their relatives had been involved in the care planning process. It was acknowledged that most residents and relatives would not wish to be involved in every review of every risk assessment and care plan. However it was suggested that each time reviews took place the resident, and/or with their consent their relative, should be informed to confirm that they were happy with the care provided. A record should be made of this contact. Consultations and visits undertaken by health care professionals were very well documented. Doctors, district nurses, chiropodist, continence specialists, diabetic specialists, and skin specialist had all been involved. Residents told the inspector that the staff were kind and looked after them well One person said that he had no complaints and he would speak out if he had another said that the staff were very kind and helpful. However one comment made in the questionnaire was ‘My mum feels frustrated at times because at 97 she does not suffer from dementia and therefore she has very few residents to talk to and hold a rational conversation. She also feels that at times she is treated as if she doesn’t know what she is talking about either’. Medication was well managed. Storage was acceptable, clean and tidy and stock levels were acceptable. The controlled drugs balanced with the record. Staff had received training and a list of signatures and initials was maintained of personnel authorised to administer medication. Training from Boots had been further supported by training from Worcester College of Technology. Records were well maintained. However allergies and ‘none known’ must be recorded. Some difficulties had been experienced in maintaining complete records of the application of topical medicines. A new system was being trial to ensure this was addressed. The records contained clear information regarding the residents’ wishes when their lives drew to an end and compliment letters and cards from relatives and friends received by the home, demonstrated that care was given with skill, sensitivity and kindness to all involved. Subject to a risk assessment and their wishes, residents are able to hold the key to lockable storage in their rooms and their bedroom door key. Mail was delivered unopened to the addressee and assistance given if required. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 13 People were able to finance their own private telephone if they wish or take and receive calls in private using the home’s phone. Visitors could be received in the communal lounges or the resident’s private bedroom according to the wishes of the resident. Staff were observed relating to residents in a friendly courteous manner. Westmead DS0000018696.V342496.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, 15, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents take part in the activities and events that are arranged for them in the home and participate in community events according to their wishes. So that they receive stimulation and motivation to continue their involvement in life. Support is made available so that residents of different faiths are able to worship according to their wishes. They arrange the structure of their day according to their wishes and make choices in many aspects of their daily life. They are able to select meals they ‘fancy’ from the menu so that they receive nutrition in an enjoyable form. EVIDENCE: The manager stated in the AQAA that residents were involved in having a say on how the home operated and how they choose to live their day. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 15 Residents meetings were arranged, there was a residents’ representative, an activity questionnaire that resulted in a varied programme, menu planning meetings that influenced the meals on offer. 1:1 outings were arranged, fundraising and positive links with the community were organised. The questionnaire responses indicated that activities were usually arranged in which some people participated and enjoyed. Some residents told the inspector that they enjoyed the quiet and privacy of their rooms and other preferred to sit in the communal lounges. They enjoyed their music, television and reading. Ladies in the lounge confirmed that there was always some thing to do and they had enjoyed the morning’s quiz. It was observed that there was good interaction between residents and the conversation in the lounges and dining room was lively. Recent activities had included word games, bingo, crafts and water painting. There had been visits from an animal specialist and the residents were enthralled to be able to see and touch rabbits, lizards, snakes and guinea pigs. A local vicar visited every two weeks and held a Holy Communion Service for those would wish to attend. Leaders from other denominations were contacted and visited as required by the residents. Some residents went out to services held by the Salvation Army. The hairdresser was busy on the day the fieldwork was carried out and it was observed that the ladies enjoyed having their hair done and socialising with other people. An activities programme was displayed on a notice board and information regarding a day trip to take place on the next Thursday. Information was also displayed regarding the residents’ meeting, the ‘cooks surgery’, the residents’ representative, ‘Having Your Say’ link, the Statement of Purpose and Service Users’ Guide and the complaints procedure. The home had a cat that had been given to them as a kitten and was much loved by the residents. In the attractive level gardens hedgehogs were observed searching for their food and staff confirmed that the residents enjoyed watching them and other wild life that entered the garden. It was observed in the records that peoples’ individual interests were recorded in the assessments and care plans, and records were maintained indicating resident’s involvement. However the daily records frequently failed to demonstrated the daily life of the individual. These records could be developed in more detail to indicate how the individual had spent their time, interaction with others, and their state of well-being. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 16 None the less the staff demonstrated that they were aware of each person’s needs and character. It was observed that a person who was visually impaired was assisted correctly when served their meal. Samples of the menus demonstrated that residents were offered a choice of dishes, and alternatives were always available. Staff were over heard helping residents to make their selection. The questionnaire responses stated that residents usually enjoyed their meals. The residents who spoke to the inspector confirmed that the food was good and they enjoyed their meals. One person said that there was plenty of choice and plenty of fresh ‘veg’. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and relatives have the information and support they need to raise their concerns and do so in confidence that they will receive a fair hearing and appropriate response. Staff are well recruited and checked to ensure they are suitable and they receive appropriate training to ensure the residents are not put at risk of abuse. EVIDENCE: Copies of the complaints procedure were contained in the Statement of Purpose and Service Users’ Guide. There were also copies displayed on notice boards. The questionnaire response indicated that residents and relatives knew how to raise their concerns. In the AQAA the manager stated that an analysis was undertaken each month of the complaints and compliments that had been received and this informed the quality assurance process. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 18 In addition staff received training relating to the protection of vulnerable adults, and information from Adult Protection Co-ordinator, CSCI and Age Concern relating to elder abuse was used. There was a constructive relationship with the Adult Protection Team and zero tolerance of abuse resulting in early referral to the PoVA register. Risk Assessments, recruitment and selection and residents involvement in care reviews all influenced their safety and well-being. The complaint record in the home for the previous three months indicated that the two complaints had concerned catering. Twenty-six compliments had been received in the same period concerning the catering. The CSCI had received no complaints, concerns or allegations concerning the service during the previous twelve months. The staff demonstrated that they were aware how to respond to complaints and concerns regarding abuse and their records demonstrated that they had received appropriate training. The recruitment process was sound and the required checks had been made before posts were offered and people commenced their duties. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 19 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, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents live in a clean, well maintained and decorated home that suits their wishes and needs. Appropriate equipment is available to assist their mobility and safety. Systems and training is in place that manages the risks of cross infection among large groups of people. EVIDENCE: The manager stated in the AQAA that each month she conducted a ‘health and safety walk about’ with the Home Manager and the Hotel Services Manager inspecting the premises. There was a regular maintenance programme, an annual management plan, aids and adaptations, and weekly and monthly equipment checks. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 20 The documents in the home demonstrated that records were being kept of all of this monitoring, checking and planning. Questionnaire responses indicated that the home was usually fresh and clean. One comment made was, ‘Some times there is a strong smell of urine but staff do their best to deal with this. Some residents are incontinent’. When the inspector arrived in the home early in the morning the odour was apparent however it was quickly addressed by the staff that attended to the matter. A partial tour of the home was conducted. The installation of a shower room on the ground floor had proved very successful and so another was planned on upper floor. The redecoration programme had continued and it was observed that the home continued to be clean, attractive, well decorated and furnished. The carpets on the ground floor were beginning to show signs of the heavy traffic that they were subject to. Residents were using the comfortable communal lounges, and the bedrooms were well appointed and personalised with the possessions of the occupant. Refreshment facilities were available in the lounges and on request from staff. Supplies of liquid soap, disposable towels and personal protective equipment were available throughout the home. Staff and their records confirmed that they had received training in infection control. The laundry was well arranged clean and tidy. The manager said in the AQAA that the home had undertaken an audit using the ‘Department of Health’ Essential Steps to Safe Clean Care’ and had scored well. An action plan was being produced to address the issues identified. The home already had in place the Health Act 2000 Code of Practice for Prevention and Control of Health Care Associated Infections and the Infection Control Guidelines for Care Homes. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff are friendly and competent, well recruited and trained so that residents receive the care they need and have trust and confidence in the carers. EVIDENCE: The manager stated in the AQAA that the home employed a ratio of one member of staff to eight residents and this exceeded the Residential Forum requirements. The staff told the inspector that they believe the staffing levels were sufficient to meet the current needs of the residents. In the past twelve months only two full time and four part time staff had left the home. The current age range was from 18 years to 64 years with the majority of people being in the 45 – 54 year age range. There was one male carer employed. 16 of the care staff were white British, one carer was African and another was Chinese. Questionnaire responses were generally positive. Comments made were Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 22 • • • • • Many of the staff go out of their way to provide an excellent level of care. As far as I am aware the staff have the skills and experience they need to look after people properly. Most care is from the daytime staff. They respond to the needs of those in their charge very well. Some staff showed considerable thought and care. There could be some improvement in night time care. The staff give an excellent service. The inspector interviewed three staff. They were all experienced staff that had been well recruited and trained. Their records and the answers they gave to the inspector’s questions supported this. They were aware of emergency procedures and the actions they should take when in receipt of complaints or concerns relating to the protection of adults. The manager stated in the AQAA that the home was working towards achieving the Investors in People Award. In the last twelve months a new recruitment and training manager had been appointed, 63 of staff had achieved or were working towards a National Vocational Qualification at level 2 and a new capability/ sickness policy and procedure had been implemented. There were plans for further training and annual health checks for night staff and staff that did ‘sleep ins’. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 23 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, 36, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed so that the staff deliver the care the residents need according to their wishes. Due attention is paid to health and safety so that the welfare of the people in the home is safeguarded. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager stated in the AQAA she had achieved the Registered Manager’s Award. Staff meetings, staff supervision and personal development reviews regularly took place. There was a commitment to equality and diversity, application of GSCC code of conduct, quality assurance monitoring and the annual home management plan. Policies and procedures were in place in relation to residents’ finances, safe working practices in relation to residents and staff, fire safety, food hygiene, first aid, moving and handling, health and safety checks and monitoring, compliance with health and safety legislation. Both the Home manager and Hotel Service manager have health and safety qualifications. A questionnaire response was, ’The service takes an active part in the well being of the persons in care. The standard of care of all parts is up to expectations’. A resident stated that the home was well managed and ran well. The home had a stable management team and was well supported by the registered providers; Heart of England. The registered manager had been in post for some time and was qualified and experienced in her role. The staff described her as ‘nice’ ‘polite’ ‘strict when called for’. Staff confirmed that they received supervision and felt well supported by the management team. Their records confirmed this. There were systems in place that enable the staff to express their views and participate in decisions regarding the service. Regular staff meetings were held and minuted. As part of the quality assurance programme the home distributed questionnaires to residents every year. These sought their opinions regarding the standard of care, catering and accommodation. In addition questionnaires were made available to relatives and professionals and their views were welcome. The documents demonstrated that the responses were read and action was taken to improve the service and respond where necessary. For example flower boxes had been provided and a green house was being obtained. In addition to the questionnaires a range of systems were regularly audited. Some of these were the comments and complaints, accidents, equality and diversity. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 25 The National Minimum Standard for Quality Assurance was broken down to demonstrate where evidence of compliance was found. These elements of a quality assurance system identified were weaknesses could be improved and the service could be developed further. Many residents had money held in safekeeping and managed on their behalf by the home. There was secure storage and good documentation. Access was restricted to the manager and deputy. Health and safety was well addressed. The AQAA indicated that systems and equipment were regularly checked and the maintenance file indicated that there was an ongoing programme of care. Policies and procedures had been reviewed in 2006 and the general risk assessments for the home were now being looked at. A maintenance book was available in which staff were able to enter their concerns, which in turn were actioned. The Fire Risk Assessment for the home was drawn up in June 2007 and a list of actions were currently being addressed. All fire safety checks were being carried out at the required frequency and staff were receiving training and participating in fire drills. Staff were also receiving training in other health and safety matters and this was endorsed by their documentation. Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 26 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 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcestershire Local Office The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Westmead DS0000018696.V342496.R01.S.doc Version 5.2 Page 29 - 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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