Inspection on 20/06/06 for Westmead

This inspection was carried out on 20th June 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westmead 03/11/09

Westmead 05/06/08

Westmead 07/06/07

Westmead 11/11/05

Westmead 16/06/05

Westmead 03/03/05

Westmead 17/06/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Westmead Leonard Cheshire Saunton Road Braunton Devon EX33 1HD Lead Inspector Dee McEvoy Key Unannounced Inspection 20th June 2006 10:00 Westmead DS0000022129.V294413.R01.S.doc Version 5.1 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 DS0000022129.V294413.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westmead Address Leonard Cheshire Saunton Road Braunton Devon EX33 1HD 01271 815195 01271 814501 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) www.leonard-cheshire.org.uk Leonard Cheshire Mrs Caroline Brennan Care Home 18 Category(ies) of Physical disability (18) registration, with number of places Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 2005 Brief Description of the Service: Westmead provides accommodation and 24-hour care for eighteen adults with physical and learning disabilities under the ownership of the Leonard Cheshire Foundation. Although their age category ranges from nineteen to sixty-five, the majority of service users are 40 years or under. The home is an older property and has been adapted for wheelchair users throughout. All bedrooms are single. Westmead is located in Braunton, a large village offering shops, banks, pubs and other amenities. The home is within easy reach of local beaches. Barnstaple is 5 miles away. The home has specially adapted vehicles available to service users, enabling them to enjoy trips. Overnight accommodation is available for visiting relatives and friends. The average cost of care is £658.00 to £970.00 per week. Additional costs, not covered in the fees, include transport, which is charged at 40p per mile, hairdressing and personal items such as toiletries and newspapers. Current information about the service, including CSCI reports, is available to prospective residents. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took nine hours to complete. During this time the inspector case-tracked 3 residents, which helps us to understand the experiences of people using the service. A number of other residents (5) were met and spoke with at length during the course of the day. The inspector also spent time observing the care and attention given to residents by staff. The inspector spoke with 8 members of staff including the manager, care and ancillary staff. One visitor was also spoken with. Prior to the inspection surveys were sent to 11 residents; 3 were returned. Nine relatives were sent surveys and 5 were returned. Surveys were also sent to 10 staff members but the Commission received no responses. 11 surveys were sent to health and social care professionals; responses were received from one G.P., one District Nurse and four care managers. Records relating to recruitment, training, health and safety and maintenance were looked at and a tour of the premises was taken. The manager had completed and returned a pre-inspection questionnaire before the inspection visit. This home has undergone managerial changes over the past year and since the last inspection a new manager had been registered with the Commission. What the service does well: What has improved since the last inspection? Care planning and risk assessments have improved ensuring that residents’ personal and health care needs are understood and met by staff. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 6 The general fabric of the home has improved, the outside has been completely re-painted and communal rooms have also been re-decorated to provide a pleasant and comfortable environment for residents. During the inspection it was noted that work was about to commenced on fitting new en-suite bathing facilities for some rooms, which will improve. Staff training has been provided to ensure that staff have the necessary skills and competencies required to meet residents’ needs. 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. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available for prospective residents, which enables them to make an informed choice before moving into the home. Residents benefit from a good admission and assessment process, which ensures that the home can meet their needs. EVIDENCE: Residents responding with surveys (3) confirmed that they had received enough information about the home before moving in so they could decide if it was the right place for them. Where possible residents and relatives are encouraged to visit and spend time at the home before making a decision to move. The statement of purpose is comprehensive and contains the necessary information. It is freely available in the home. A minor amendment is to be made to ensure the details of the registered manager are accurate. As part of case tracking, three residents’ care files were looked at; preadmission assessments are completed by the referring professional, usually a social worker, and the home completes a comprehensive assessment which includes input from the manager, team leaders and other health professionals such as physiotherapist and speech and language therapist. Assessments looked at demonstrated that all needs were covered in the areas of health, personal and social care needs. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are good and reflect the residents’ needs ensuring that staff have the information they need in order to satisfactorily meet the needs of the residents. Residents’ rights and independence are respected and promoted; residents are encouraged to undertake an independent lifestyle, when staff assistance is available. EVIDENCE: Residents spoken with were generally happy with the care. 3 responding with surveys said they “usually” received the care and support they needed, and most relatives and health and social care professionals indicated they were also generally satisfied but areas of improvement were identified, for example staffing levels appeared to affect the quality and delivery of care at times (refer to standard 33). Care plans were generally good; they were detailed and gave a clear picture of the residents’ needs and preferences, ensuring that staff were aware of individual needs and goals. It was particularly good to see personal histories Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 10 and life stories, which gives a sense of who this person is. Regular reviews indicated that care plans had been discussed and agreed with residents or their representatives. However evaluations of care were often brief, not showing whether care had been appropriate or successful in meeting residents’ needs. The physiotherapist has completed excellent manual handling plans to guide staff when moving and handling residents. Residents spoken with (4) said that that staff generally respected daily preferences and decisions, for example what time they got up or how they are addressed and who provides their care. One resident told the inspector that the new manager would encourage and support residents’ independence. Three residents felt that staffing levels effected some decisions and choices regarding activities. During the inspection staff were observed to care for residents in a competent and friendly way and demonstrated a good understanding of residents’ individual needs and character. Staff communicated well with residents using their preferred means and on occasion skilfully assisted the inspector when communicating with individual residents. Comprehensive risk assessments were available which included behavioural, situational and environmental risks; for instance, one behavioural risk assessment highlighted hazards and the control measures in place to reduce them. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities provided do not always match residents’ expectations and preferences or satisfy their social and recreational interests and needs. The home provides varied and nutritious meals, which take into account residents’ preferences, however the current dining arrangements do not suit the residents’ needs or wishes. EVIDENCE: One of the areas identified for improvement by residents, relatives and staff was activities. Residents spoken with (7) and those responding to surveys (3), left that activities were often limited due to staffing levels, particularly at weekends and evenings. Minutes of a residents’ meeting in May quoted one resident as saying, “are we not allowed fun anymore?” Relatives (2) were also concerned that the more dependent residents’ social needs, particularly outings and trips, were being ‘overlooked’. The social activities records were looked at for two dependent residents; these mainly stated “in the computer room” or a brief note to indicate activities undertaken within the home, such as painting or cooking; each had only one entry to confirm that they had been out Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 12 on a trip/outing since January. One of these two residents told the inspector that they would like the opportunity to get out more often. Other residents (2) said that they would like access to the computer room over the weekends and evening, one described the computer as “my life line”. The computer room is currently available weekdays only. On the day of the inspection several residents enjoyed a trip out for a pub lunch, but several (7) were seen to spend the morning sitting in reception or the dining area with little or no stimulation except for the TV. Two parents and one professional felt that there seemed to be a lot of “group TV watching”. Three residents mentioned the inhouse training available at the home, which was described as ‘interesting’ and ‘valuable’. Residents (3) said that they would like to raise the profile of the home in the local community and re-establish the volunteer group, which had provided community contact and activity in the past. This is an issue to be taken forward through the residents’ regular meetings. Visitors to home, including relatives and professionals, said they felt welcome to visit the home and that the staff generally communicated well with them. Residents said they could have visitors anytime. One visitor spoken with during the inspection described the home as ‘friendly and welcoming’. All residents spoken with (7) described the food as ‘good’ or ‘excellent’; other comments included, “The quality is good”, “There is always a choice” and “Our cooks are brilliant”. Three residents responding to surveys said that they “usually” liked the food at the home. Some residents (3) and relatives (2) were unhappy with the current dining arrangements; this had also been an on-going topic at residents’ meetings. The main concerns around the arrangements were that the up-stairs lounge was rarely used by residents meaning the dining area became a sitting room too, with some residents spending lengthy periods of time in this one space. Other concerns were raised about the space and general lay out of the dining room, which was described as “cramped”. During the inspection it was observed that areas of the dining room were hard to move around and could cause difficulties in an emergency, for instance during a choking episode. These arrangements are to be reviewed as soon as possible to ensure that residents’ wishes are acted upon. Mealtimes continue to present a challenge for staff, with the majority of residents requiring full assistance. The inspector was present at breakfast, lunch and supper. As previously reported it was seen that staff assist two residents at the same time with their meal. The inspector observed residents waiting for assistance with their meal with staff trying to meet the needs of each individual. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the residents’ personal support needs, and the health needs of residents are met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the management and administration of medications are generally good. EVIDENCE: Residents spoken with (7) and those responding to surveys (2) said they “always” received the personal and medical support they needed and were generally happy with the overall care they received. Staff spoken with demonstrated a good understanding of residents’ personal and health care needs and this was evident from the positive relationships, which have developed between them. Two residents said that staff assisted them appropriately, one said, “I get all the help I need.” However one resident described waiting over an hour an occasion for assistance with personal care. Several residents praised the services of the physiotherapist; one described the physio as “brilliant” and explained how they had benefited from individual sessions. One parent was also very happy with the physio service saying, ‘physio levels have improved greatly’. One G.P and district nurse were Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 14 generally satisfied with the overall care provided and felt that the home communicated clearly. They felt that staff “usually” demonstrated a clear understanding of the residents’ needs. Individual care notes contained evidence of some good multidisciplinary work; residents have access to dietician, speech therapist, chiropodist, physiotherapist and other health professional as necessary. Staff administering medication have undertaken training and reviews to ensure that safe practice is maintained. Since the last inspection staff have received the appropriate training to allow them to administer medication usually administered by a registered nurse. The local district nurse has agreed that trained staff can undertake this delegated task and guidelines are available for staff to follow. The home has worked with medical staff to ensure that residents’ medication has been reviewed appropriately. Medication was stored and recorded appropriately. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that residents feel their views are listened to. Arrangements for the protection of vulnerable adults are in place. EVIDENCE: Residents spoken with (7) knew who to speak with should they have concerns or complaints but some (3) felt that responses and action were ‘slow’. One resident commented; “We talk about things but nothing changes”. Residents gave the examples of the dining room situation, staffing levels and activities as on-going and un-resolved concerns. One parent was also disappointed not to get a response from concerns raised with the manager. The Commission has received no complaints or concerns about the home since the last inspection. The home has robust policies and procedures for responding to suspicion or evidence of abuse or neglect. Staff spoken with had received training to ensure that they are aware of adult protection issues and know how to report any concerns. Residents spoken with, with the exception of one, said they felt safe at the home and were generally well cared for. One resident said, “The staff are wonderful”, another said, “The staff are very nice to me”. Two residents felt that younger staff could be more respectful, for example not playing the radio “at full blast”. The arrangements for dealing with residents’ money were generally satisfactory. Residents are supported to take control of their personal finances where possible. The accounts of two residents were looked at; each account is Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 16 kept securely in a locked space. Access is limited to members of staff. Each account has records and receipts kept. Balances were checked and were found to be in order. It was noted that two signatures are not always obtained for each transaction, which is good practice and improves accountability. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the décor and cleanliness within the home is generally good but aspects of the environment do not meet individual residents’ needs. EVIDENCE: The home has been adapted to accommodate wheelchair users, who were seen to be able to access most parts of the home and some areas immediately outside the home. A passenger lift provides access between the floors. The home was generally comfortable and safe; it was clean and free from offensive odours. All bedrooms are single occupancy and those visited by the inspector were personalised and comfortable and reflected individual tastes. Communal areas are bright and well decorated. The exterior of the building has been re-painted in the original colours, as requested by the residents. As previously reported, six of the bedrooms have en-suite facilities however only one is currently usable. As a result, 17 residents use three bathrooms; this is not ideal. Since the last inspection quotes have been agreed for the refurbishing of en-suite facilities to ensure individual residents’ independence, privacy and dignity are meet. The inspector was told that building work was to Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 18 start within the next two weeks. Once completed these facilities will improve the general bathing amenities. Some specialist equipment, such as environmental control systems, could improve residents independent. Some residents cannot use the call bell system available. One resident described “calling out” for assistance when needed but said they could alert staff more easily if the right equipment was available. One parent also raised the lack of this of type of equipment as a concern. The laundry facilities were clean and well organised; a sluicing sink and hand washing sink are available and the floor and wall finishes are impermeable and readily cleanable. The home has a dedicated laundry worker; the overseas volunteers also assist with laundry duties. The member of staff on duty in the laundry had received the appropriate infection control and health and safety training. Liquid soap and paper towels, and gloves and aprons, are freely available around to the home to ensure good infection control. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty is not always sufficient to meet individual residents’ needs, preferences and expectations. The procedures for recruiting new staff are robust and offer protection to residents. Staff receive mandatory and specialist training that should promote residents safety and wellbeing. EVIDENCE: Although residents were generally happy with the care provided, insufficient staff being on duty sometimes affected the delivery of care. Residents spoken with (5) felt that staffing levels impacted on a variety of activities and other issues (refer to standards 7, 12, 17 & 18). Relatives responding to surveys (4) felt there was insufficient staff on duty, particularly evenings and weekends, to meet the individual needs of the residents. Staff spoken with (5) were frustrated at times by staffing levels, one said, “Some residents are very dependent and need our time and patience”, another said, “We would like to do more with the residents”. During the inspection it was noted that three care staff took a lunch break at the same time leaving one member of staff with at least 7 residents. This deployment of staff was discussed with the manager to ensure that there is always sufficient staff ‘on the floor’. The home has Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 20 experienced moderate staff turnover since the last inspection but continues to recruit. Four staff recruitment files were looked at, including two for overseas volunteers. All but one contained the necessary information to ensure the protection of vulnerable adults. One volunteer was awaiting the return of a full Criminal Record Bureau (CRB) check; the manager assured the inspector that the volunteer was supervised at all times and did not have unsupervised access to residents. Robust recruitment of agency staff was seen with excellent confirmation of staff details provided by the agency. Staff appeared to be interested and motivated by their job; one said, “I really enjoy my job”. Staff spoken with had a good understanding of the residents’ needs and preferences. One staff member talked about the “good training” available and another described a thorough induction period. Mandatory training such as fire awareness, first aid and moving and handling is available to all staff, and residents if they wish. Other training includes safe handling of medication; care planning, NVQ and training specifically related to residents needs. Two staff are completing a physiotherapy assistants course. Currently 23 of staff have attained a national recognised qualification in care (NVQ), with a further 27 working towards completing NVQ 2. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from the experience and friendly approach of the manager. The systems for consultation are good, with a variety of evidence that indicates that residents’ views are sought. Health and safety within the home is promoted. EVIDENCE: Since the last inspection a new manager has been appointed and registered with the Commission. The manager has the necessary experience and is working towards the necessary qualifications. Residents and staff described the manager as ‘approachable’ and felt that they could talk to him. The manager is settling into his post and has some good ideas for improvements and is committed to increasing residents’ independence. Quality assurance systems are in place; annual satisfaction questionnaires are sent to all residents and other interested parties, such as relatives. Minutes of Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 22 regular resident meetings are available and demonstrate the involvement of residents. Evidence was also seen of resident involvement in planning some activities and meals. However, several residents felt that their views were listened to but not always acted upon (with particular reference to the dining room, activities and staffing). The inspector toured the building and looked at a number of servicing and maintenance records. On the whole health and safety is well managed. Equipment, such as the lift and hoist are serviced and maintained regularly and fire safety was well managed on this occasion. Several residents had attended fire safety training recently. Thermostatic valves deliver water at a safe temperature to all taps; daily records are kept of bath temperatures. The radiators in communal areas have been covered to prevent accident and radiators in residents’ bedrooms are guarded, others are behind items of furniture and were assessed as not posing a significant risk. Window restrictors are fitted to all ground and first floor windows to prevent falls. Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 1 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? 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 YA14 Regulation 12 (3) Requirement The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. (Particular consideration must be given to planning social and leisure activities, which meet residents’ preferences and expectations.) Timescale for action 29/09/06 2. YA27Y 23 (2) (n) The registered provider shall 27/10/06 ensure that suitable adaptations are made, and such support, equipment and facilities as may be required are provided for residents (This refers to the need to review the bathing facilities, including en-suite, to ensure that residents’ assessed needs are met and that facilities offer sufficient personal privacy and independence) (Previous timescale of 30/12/05 not met) Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 25 3. YA33 18 (1) (a) The registered person shall having regard to the size of the care home, the Statement of Purpose and the number and needs of the service users shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. 25/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations It is recommended that mealtimes be monitored to ensure that sufficient staff are available and individual needs and preferences are met. It is recommended that the dining area currently used is reviewed as requested by residents and relatives. It is recommended that action be taken to address residents’ or relatives’ concerns in a timely way and with a satisfactory outcome. It is recommended that two signatures be obtained when dealing with residents’ personal finances. It is recommended that the use of specialist equipment be explored to improve the independence of residents. It is recommended that the home act on the views and wishes of the residents and supply a copy of quality assurance reviews to the Commission and make a copy available to residents. 2. 3. 4. 5. YA22 YA23 YA29 YA39 Westmead DS0000022129.V294413.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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. 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