Inspection on 05/06/08 for Westmead

This inspection was carried out on 5th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westmead 03/11/09

Westmead 07/06/07

Westmead 20/06/06

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 28/09/2008.

CARE HOME ADULTS 18-65 Westmead Leonard Cheshire Saunton Road Braunton Devon EX33 1HD Lead Inspector Jo Walsh Unannounced Inspection 5th June 2008 09:15 Westmead DS0000022129.V362505.R01.S.doc Version 5.2 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.V362505.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 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.V362505.R01.S.doc Version 5.2 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.LCDisability.org Leonard Cheshire Disability Position Vacant Care Home 18 Category(ies) of Physical disability (18) registration, with number of places Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2007 Brief Description of the Service: Westmead provides accommodation and 24-hour care for nineteen 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 for single occupancy only. Westmead is located in Braunton, a large village offering shops, banks, pubs and other amenities. The home is within easy reach of local beaches and Barnstaple is 5 miles away. The home has specially adapted vehicles available those who live at the home, enabling them to enjoy trips away from the home. Overnight accommodation is available for visiting relatives and friends. The cost of care can be obtained directly from the service. Additional costs, not covered in the fees include transport, which is currently under review, hairdressing and personal items such as toiletries and newspapers. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk Current information about the service, including CSCI reports, is available from the main office. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place during a week day in June and focussed on the views of the people who live at the home. Time was spent talking to the people who live at Westmead House as well as the staff and some visiting relatives and friends. We also looked at some key documents including plans of care, medication records, staff files, training records and records relating to individuals monies. This helps us to understand how well the home is run. The manager was available throughout the inspection and explained that he is in the process of applying with CSCI to be the registered manager. The manager ensured that a very detailed Annual Quality Assurance Assessment (AQAA) was sent to us prior to the inspection taking place. This gives us information about how the home maintains a safe environment, what staff training has been implemented and how they monitor their quality of care and support. This information has helped to inform the inspection process. Prior to the inspection taking place we also sent some surveys to people who live at Westmead and to relatives. Their views along with comments from face to face interviews during the inspection are included throughout this report. What the service does well: Westmead House provides people with a safe homely environment that has adaptations to enable people to be as independent as possible. People who live there said • I like my room, I have everything I need. • It has its ups and downs living here, but they work very hard to make sure the place is clean and we can choose who we want our rooms. • The new manager is good at giving us more choice about the home, we are getting a washing machine in our bathroom so that we can help do our own washing. • The communal areas are clean and fresh but my room has damp due to a leaky roof. I have discussed the matter and am still waiting for a solution. Surveys from relatives included the following comments Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 6 • • • • • • This is a good well run establishment which like most places has its ups and downs but it provides a happy atmosphere and is efficiently run. Basic care is excellent, the environment is clean, welcoming and cheerful. The meals I have seen appear very appetising. Staff generally show a genuine liking for and empathy with residents. There is a lot of laughter. It gives a safe comfortable happy home. We greatly appreciate the care the staff provide and also the friendly welcome we receive when visiting. Care is usually good and cleanliness and a lot of the décor has been redone lately. Individuals are fully involved in the development and review of their plans of care. Weekly key worker time gives people the opportunity to discuss what goals and wishes they want to work towards and allows people to have a greater say in how their care and support should be delivered. The staff group provide quality care and support, are well trained and supported to do their job. Comments from people who live at the home included • Staff are friendly and very helpful, always cheerful and willing to help at any time. • I would recommend living here, staff do their best. • Staff numbers are up and down, most staff are really good, but I would like more staff so I could do more things. • Staff are nice. • I like some of the staff, but some are not as good, which I have told the manager. The home provides a good range and choice of food. People who live at Westmead said • The food is very good. • Food is quite good, we get to talk about what should go on the menu • We should have more than two choices, I would say it is 2 star not 5 stars. There are good systems in place for ensuring the views of people who live at Westmead are taken into consideration. Regular meeting and inclusion in staff recruitment are some of the ways the home include individuals to be involved. Complaints and concerns are taken seriously, listened to and actioned. One relative commented ‘’I have only had cause to complain twice in 17 years and it was dealt with quickly and fairly.’’ Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? A manager is now in post and is in the process of applying to CSCI to be the registered manager. The people who live at Westmead all spoke highly of the new manager. Comments included • James has improved a lot of things, new shift patterns and I am now in charge of my own finances. • James has got a task and a half but he can do the job. I have confidence in him. I feel we can make a complaint and he listens. • He is doing a good job. • He is fantastic, he has dealt with my complaint. Staff spoken to during the inspection also spoke highly about the new manager and said that his management approach was open and inclusive. New call bell systems have been installed that have been adapted the suit the needs of the people who live at the home. The system includes voice activation, computer software activated systems, specialist touch pads and pendants for use when exploring the grounds of the home. This is an excellent improvement that enables people a greater degree of independence. People who live at Westmead and staff have received training in the use of a system of words and symbols (WASP). This means that regular meetings are recorded in a format that people can easily understand, promoting greater involvement and opportunity for feedback. A volunteer coordinator has been recruited to enable the home to develop and increase the number of volunteers. This enables the home to provide a greater range and choice of activities that suit the needs of the people who live there. A daily planning system has been implemented that gives people who live at the home opportunity to have a say in what activities and outings happen each week. The manager is looking at changes in shift patterns of staff to allow greater flexibility and better suit the needs and wishes of people who live at Westmead. A new conservatory to extend the dinning area has been agreed with consultation from the people who live at Westmead. Work on this building will commence shortly. Other areas of the home have been refurbished and people who live at the home have been given a budget and supported to purchase items of their choice for their corridors. A sensory garden is being developed in conjunction with help from the local community. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 8 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 DS0000022129.V362505.R01.S.doc Version 5.2 Page 9 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.V362505.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential new people benefit from a good admission and assessment process, which ensures that the home can meet their needs. EVIDENCE: Pre admission assessments were not specifically looked at during this inspection as this was looked at in depth during the previous inspection. The manager gave a detailed account of what systems are in place for ensuring assessments take place prior to them offering a placement at the home. This information was detailed in the AQAA and one person did confirm that prior to moving in they were visited by staff at the home, and that they had opportunities to visit the home on several occasions to meet staff and other people who live there. The previous inspection report said ’the files of three people living at the home were looked at, including that of the most recent admission. All three contained detailed pre-admission assessments completed by the referring professional, usually a social worker. The home completes their own in depth assessment that includes input from the manager, team leaders and other health professionals such as physiotherapist and speech and language therapist. The assessments showed that all needs were looked at in the areas of health, personal and social care. The assessments also contained an Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 11 assessment of how many staff hours would be needed each week in order to ensure the identified needs would be met.’ Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 12 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. 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. Individuals’ care is well planned so that staff has good information to ensure that personal, health and social needs are met in a way that allows people to have choice and control in their lives. EVIDENCE: Three plan of care were looked at with the individual they concerned. Everyone has a copy of their plan in their room, and it is clear that they have been involved in the development and review of the plans. Plans of care cover areas such as ‘What I Like to do’, Good Things About Me’, ‘What things I Like to do’, ‘What Things I don’t Like’ and ‘What I do Now’. There are also sections for goals and action plans. The home have worked hard to look at how they can empower and enable individuals to be more involved in planning their care by using photos and words and symbols. Plans of care gave a good picture of what the needs and wishes of individual were and how staff should assist them in daily living tasks to ensure care in delivered in a person centred way. Environmental and situational risk Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 13 assessments had been completed and included, the use of bed rails and wheelchairs and for those wishing to administer their own medication. Some plans had detailed moving and handling plans that had been developed and reviewed by the physiotherapist. There was also visual guidance, photos of how individuals should be positioned to ensure they were comfortable and safe. This was discussed with some staff who said this information was crucial to providing the right care to individuals. Staff said that plans of care were very clear and helped them to do their job effectively. Staff showed a clear understanding of individuals’ needs and ways of communicating. People who live at the home gave examples of how they are in control of their lives and are assisted to make choices about what they do. Most people did say they would like the opportunity to go out more. Several people commented on the fact that a daily planner had been introduced that looked at who was doing what each day. Two people commented on the fact that this did not allow for much spontaneity. Other comments included • I do have freedom of choice, however more often than not the choice is limited by staff numbers. • I can do what I want to a degree if staff are available. The manager and staff are aware that choice is sometimes limited by staffing levels and have tried to address this by use of volunteers and looking at different shift patterns that better suit the needs of the people who live at the home. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westmead offers people opportunities to engage in social, educational and leisure activities EVIDENCE: As stated in the previous section most people spoken to and those who returned surveys said they would like more opportunity to go out more. There are limitations due to staffing levels, however the home have worked hard to ensure that individuals are supported to take part in a wide range and choice of activities. The manager highlighted in the AQAA that some people are given one to one support to be involved in voluntary work and advocacy groups. They have provided 1:1 support for two people who work for People First (an advocacy group) on a weekly basis. 1:1 support and transport for an individual who has been elected as a south west representative on the Service User Network Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 15 Association and the same support for someone else who has been recruited to work for the LCD National Campaigns Team, and 1:1 support for an individual supporting the Police to raise the profile of the police force and foster community links. The home also provides 1:1 support for several individuals who attend college courses. The Home is working in partnership with a local college to give some individuals the opportunity to work as part of the administration of the home. They will be paid and assessed for an NVQ in customer services by the college. The manager describes this development as a ‘step for individuals sourcing paid employment in the community’ The home makes good use of volunteers to assists people to get out and about in the local community and since the last inspection a volunteer coordinator has been recruited to enable the home to develop and increase the number of volunteers and ensure they are trained and supported. Relatives who returned surveys said • As usual in this sort of home the staff are very limited to the time that they can spend with each individuals needs and although the general care is good it’s the little needs of the residents that makes all the difference to the lives they live. • I believe Westmead do as well with supporting people to live the life they choose as anyone can expect. No one can be guaranteed the life they choose unless resources are infinite which they are not • I personally feel my relative has had too much freedom to lead the life they chose, refusing offers of help when they needed it. • Residents have a large say in how the home operates and their wishes are acted upon where appropriate and practicable. • There is a programme of activities and outings, resources limit this and I know they would like to do more for the residents. The overall comments and feedback from relatives was very positive and most felt that within the limits of the staffing levels Westmead offered good care and support to people. Some relatives commented that communication from the home had not always been good, but the indication was that this was improving. Most said that their relative was assisted to keep in touch and that they were made welcome to the home. One visiting friend said that they could visit and pop in at any time and were always made welcome. The manager and staff team are looking at ways of giving individuals more responsibility and say in the running of the home. The introduction of corridor teams means that a staff team will work with a group of people within that corridor to enable them to make choices about the décor and future way the home runs. One person said they had been asked to be their corridor Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 16 representative and was looking forward to doing this job. They said ‘’It is a good way of getting us more involved and being part of making decisions. Individuals are also supported to train to interview for staff, so that they can have a say on who is employed to work with them. The home provides a good range and choice of food. People who live at Westmead said • The food is very good. • Food is quite good, we get to talk about what should go on the menu • We should have more than two choices, I would say it is 2 star not 5 stars. One of the cooks was spoken to during the inspection and they confirmed that menu plans are chosen around what individuals say they like and want. Any food that is liquidised is done for each item of food, not the whole meal in the blender. This allows individuals to taste each element of the meal. Support for people who need assistance during meal times is done in a caring and respectful manner. The extension to the dinning area will improve the facilities and ensure that there is ample space for everyone to enjoy their meals together. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 17 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. 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. People who live at Westmead can be confident that their personal and health care needs will be fully met. EVIDENCE: Plans of care looked at detail how staff should support someone in their personal care, and staff were observed to be supporting people in a way that promoted independence and gave the individual respect and dignity. Daily records show that staff monitors individuals health and emotional well being and liaise with other health care professionals such as doctors, community physiotherapist and other care team specialists. Individual care notes contained evidence of some good multidisciplinary work, involving a dietician, speech therapist, chiropodist, physiotherapist, dentist and others as necessary. The service contracts and pays for physiotherapist input to ensure that individuals receive the support they needs, and that staff have the right Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 18 guidance. They also have a physiotherapist assistant for 16 hours per week to ensure that exercises and specialist programmes devised by the physiotherapist are followed up. People who live at the home and relatives who returned surveys were generally happy with the care and health are support. One relative did comment that this was an areas the home could improve on and said ‘’ they do not always keep us in the lop with respect to health care needs.’’ The homes medication system was looked at and discussed with the senior person on duty. There is a good recorded audit trail for all medications received administered and returned. Medications are kept secure and only staff who have had training in safe administrations and recording take on this role. Information has been given to the manager about when it is okay to double dispense, i.e. to take a medication out of the blister pack. This would be acceptable practice if for example a person is going out with a family member and they do not wish or need to take out the whole blister pack of medications. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals’ views are listened to and acted upon. EVIDENCE: People spoken to who live at the home said they knew how to make a complaint and that they were confident it would be dealt with. One person gave an example of a complaint they had made and said they were happy that their view was listened to and the matter was resolved. The home has a complaints procedure that is in a format individuals can understand, and any received are recorded with clear actions as to how the home resolved issues raised. One relative commented ‘’I have only had cause to complain twice in 17 years and it was dealt with quickly and fairly.’’ The home ensures that there are clear policies and procedures in place for staff and individuals to be able to alert someone if abuse is suspected. The manager and staff are working with external agencies to ensure any reported issues are followed up. Staff have training in the protection of vulnerable people and the service has access to use their regional complaints coordinator and external advocates if needed. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 20 The manager has introduced different ways of individuals having support to manage their monies. In the past the home held peoples bank cards in the office safe. They are working to change this so that individuals have more responsibility for their finances where possible. There is still a clear audit trail to ensure that people are protected. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westmead provides people with a clean homely and well-maintained environment. EVIDENCE: Since the last inspection there has been a considerable investment in ensuring that both the communal areas and individuals bedrooms are redecorated and homely. This has been with input from individuals who live at the home. Most areas of the home are now well decorated and furnished to a reasonable standard. Individuals’ bedrooms are personalised and most people spoken to said they were happy with their rooms and communal areas. New call bell systems have been installed that have been adapted the suit the needs of the people who live at the home. The system includes voice activation, computer software activated systems, specialist touch pads and Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 22 pendants for use when exploring the grounds of the home. This is an excellent improvement that enables people a greater degree of independence. The home is about to have a new conservatory, which will extend the dinning area by 30sqm. The home has been adapted to meet the needs of individuals who use wheel chairs, and there is specialist equipment such as overhead hoisting equipment, electrically operated beds that allow individuals autonomy. Some of the ensuite bathrooms need further equipment to make them more useful for the individual, for example one person is awaiting a different commode chair for over the toilet. The home was clean and fresh smelling and since the last inspection it is clear great efforts have been made to make the home more welcoming and comfortable. There are good policies procedures and practices in place to ensure good infection control and the home have been assessed by the Environmental Health Department as being 5 stars for their standard of hygiene and safety. This is the highest score a home or establishment can receive. A sensory garden is being developed with the help of a local community group, this will further enhance the outdoor space. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff group are well supported and trained to do their job effectively, but improvements are needed to ensure people are fully protected by a robust recruitment process. EVIDENCE: The staffing levels are sufficient for the number and needs of the people who live at the home, but this is the one area that individuals made the most comments about. Most people who live at the home said that staff were caring, but that there were times that there were not enough staff on shift to ensure that all needs can be met. One person said that ‘’ I would like to be able to go out more than once a week, but staffing can be a problem.’’ Another person said ‘’ Agency staff do not always understand how to help me as well as the staff group who have been here longer.’’ The manager is currently looking at ways of increasing staff hours via a different staff rota to give more flexibility to ensure that individuals are enabled to go out and about more. The home also makes use of volunteers to assist in taking people out, and they have recruited a volunteer coordinator to facilitate and support this further. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 24 Staff spoken to said that they have good opportunities for training and the home employs a training coordinator to ensure that training needs are identified and met. All staff have training in areas of health and safety as well as opportunities for more specialised training in helping them to understand the needs of the individuals they support. Staff are encouraged and supported to do National Vocational Qualifications in care. The home currently has 30 permanent staff, 10 have NVQ 2 or above in care and a further 7 are working towards achieving this. Four staff files were looked at to ensure that people are protected by robust recruitment procedures. One file only contained one reference and another showed that the staff member had started prior to references being obtained. The manager said that staff start with an induction programme and would not be left unsupervised until all checks and references had been obtained. All files had checks completed to ensure individuals were suitable to work with vulnerable people (criminal record and POVA checks.) Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,37,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run in the best interests of the people who live there. EVIDENCE: The manger in post is experienced and qualified to run the home. He is in the process of applying to CSCI to be the registered manager of Westmead. People who live at the home were very complimentary about the manager, comments included • James has improved a lot of things, new shift patterns and I am now in charge of my own finances. • James has got a task and a half but he can do the job. I have confidence in him. I feel we can make a complaint and he listens. • He is doing a good job. • He is fantastic, he has dealt with my complaint. Staff said that the management approach of the home was open and they felt their views were listened to. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 26 There are good systems in place for ensuring the views of people who live at Westmead are taken into consideration. Regular meeting and inclusion in staff recruitment are some of the ways the home include individuals. Quality assurance and reviewing the support and care practices of the home include ensuring the views of the people who live there are included in this process. They do this by questionnaires, regular meetings using words and symbols to ensure everyone can have their say and understand what is being or has been discussed. The registered provider also does monthly unannounced visits to the home that includes talking to people who live there, the staff and spot checks on records and the environment. The home has achieved Investors in People award, which is a nationally recognised award to services who show commitment to training and supporting staff. This award is externally verified. Staff have training in all areas of health and safety to ensure they can do their job safely and competently. Policies and procedures are in place for all safe working practices and the home provided information prior to the inspection to show the maintain the environment and all equipment, so these were not directly checked during this inspection. Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 27 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 x 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 28 No 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 YA34 Regulation 17 Requirement The home must ensure that records are kept for all staff as detailed in schedule 4. (this relates to ensuring 2 references are obtained for all staff before they commence employment) Timescale for action 30/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations You should ensure that mealtimes are monitored and that sufficient staff are available to meet individuals’ needs and preferences Westmead DS0000022129.V362505.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000022129.V362505.R01.S.doc Version 5.2 Page 30 - 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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