Inspection on 07/06/07 for Westmead

This inspection was carried out on 7th June 2007.

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 7 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Westmead Leonard Cheshire Saunton Road Braunton Devon EX33 1HD Lead Inspector Sue Dewis Unannounced Inspection 07 June 2007 10:15 Westmead DS0000022129.V336512.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.V336512.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.V336512.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.leonard-cheshire.org.uk Leonard Cheshire Mr John Peter Windley Care Home 18 Category(ies) of Physical disability (18) registration, with number of places Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 June 2007 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 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 currently ranges from £678.65 to £963.70 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. 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.V336512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours, one day at the beginning of June 2007. The registered manager left some while ago, and the manager that was subsequently appointed has also left. There is currently a temporary manager covering the home while the post is being advertised. The temporary manager arrived shortly after the inspection started and was available for the rest of the inspection. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. During the inspection three residents were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of people living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. As part of this, questionnaires were sent out to 16 people living at the home, 17 health and social care professionals (including GPs and care managers), 10 relatives and 22 staff. At the time of writing the report, responses had been received from 9 people living at the home, 8 health and social care professionals, 6 relatives and 5 staff. During the inspection 2 people living at the home were spoken with individually and a further 3 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 6 staff including the manager. A tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. What the service does well: There is a warm and caring atmosphere throughout the home due in no small part to the positive relationships that have formed between people who live and work at the home. There is a good pre-admission assessment procedure. This ensures that people thinking of moving into the home have enough information with which to make a decision, and also know the home can meet their needs. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 6 Staff are well trained and motivated and know their duty to report bad practice. There is comprehensive care planning system that helps staff deliver the care that people need. Personal and health care needs are well met and medication is administered in a safe manner. 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 DS0000022129.V336512.R01.S.doc Version 5.2 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.V336512.R01.S.doc Version 5.2 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. 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. Individuals are encouraged to visit the home and an assessment of the support they require ensures that the home can meet their care needs. EVIDENCE: Nine people living at the home confirmed on their surveys that they felt they had received enough information about the home before they moved in. This helped them to decide if the home was right for them. Wherever possible people are encouraged to visit the home and spend time there before making a decision about moving in. 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. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 9 The assessments also contained an assessment of how many staff hours would be needed each week in order to ensure the identified needs would be met. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 10 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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place, and this generally provide the information that staff need in order to satisfactorily meet the needs of individuals and minimise environmental and situational risks. Individuals’ views and choices are not always taken into account. EVIDENCE: Individuals indicated on surveys and talking with us that they were generally happy with the care they receive. Nine 3 responding with surveys said they could make decisions about what they did each day providing there was enough staff on duty. Most relatives and health and social care professionals indicated they were generally satisfied with the care people receive, but areas Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 11 of improvement were identified, for example staffing levels appeared to affect people’s choices and the quality and delivery of care at times. Individuals spoken with 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. A ‘gender preference’ form indicated which gender of staff the individual preferred to receive their personal care from. The care planning system has recently been changed and personal information is now recorded in documents called ‘My Portfolio’. These are user friendly documents and 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. However, these had not been completed for one of the files inspected. Also, one of those that had been completed contained non- specific goals. For instance it stated a goal as being ‘to go out more’. But there was no indication as to how many times the individual went out usually, and therefore no way of knowing how much ‘more’ was. Regular reviews showed that care plans had been discussed and agreed with individuals or their representatives. Comprehensive manual handling plans had been completed by the physiotherapist. Some excellent guidance was available with regards to individual postural needs, which ensured that residents were as comfortable as possible at all times. Environmental and situational risk assessments had been completed and included, the use of bed rails and wheelchairs and for those wishing to administer their own medication. Behavioural risk assessments highlighted hazards and there were monitoring forms being used when needed. However, there were no instructions for staff on how to deal with any such incidents. Staff expressed a clear understanding of peoples’ needs and their methods of communication. A staff member assisted the inspector when communicating with several people. One staff member has recently attended an ‘empowering course’ in order to help them offer more choices to people living in the home. The local Communications Officer for Leonard Cheshire was visiting the home and was spoken with. She spoke of her role in assisting individuals in communicating with others. Some tools that are available range from the most simple, such as a photo album to ‘high tech’ computers controlled from ‘dots’ stuck to the individual’s forehead. One such communicator was being trialled by an individual and was being ‘tweaked’ to meet their needs and abilities. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 12 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 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some activities and outings are provided they do not always ensure that social and leisure needs of individuals are met, particularly those with complex needs. EVIDENCE: As on previous inspections the issue of activities and outings was raised. The vast majority (16) of surveys that were returned indicated that individuals could only do what they wanted to do if there was enough staff on duty. Four surveys returned from care managers also indicated that that people were only supported to lead the lives they choose when there were enough staff on duty. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 13 Most of the people living at the home are younger and said they wanted to ‘go clubbing’ out to the pub and to watch football. However, the opportunities for these activities are severely limited, again due to staffing levels. Still, while we were at the home, 3 people were carriage riding and one was at a ‘People First’ meeting. Most of the time people in the home watch TV read or use the computer room. People did say that they still managed to get out on the mini bus, for walks down to the town and to the pub. However, one staff said that because of staff shortages outings were sporadic. Several people were enjoying time in the computer room either, sending emails, surfing the net or playing games. Unfortunately this much enjoyed facility is not available to them at weekends due to staff shortages. Staff said that they tried to involve the home in the community as much as possible and one person told how they worked as a volunteer for a local children’s hospice. Representatives indicated that they were made welcome when they visited the home and that the individuals they knew at the home was enabled to keep in contact with them, usually via email. People that were spoken with were very complimentary about the food served to them. They said that there was a good variety and always a choice of main meal. The food that we saw served looked appetizing and nutritious. Dining arrangements have been changed so that the upstairs room is now used for those individuals who need assistance with eating. This means that they are able to get the help they need and there is more space in which people can move around in the dining room downstairs. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 14 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 and 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 individuals’ personal and healthcare support needs, with evidence of good multi-disciplinary working taking place on a regular basis. All medicines are stored securely and policies and systems provide for safe administration. EVIDENCE: As previously reported in standard 7 individuals feel that they are generally supported to make decisions about their lives, including aspects of the personal care they receive, how they receive it and who from. However, these decisions are affected by staffing levels and there are times when their wishes cannot be respected. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 15 People were generally happy with the support and overall care they received. Staff spoken with demonstrated a good understanding of residents’ personal and health care needs, and were able to describe how needs are met and how any changes to needs are communicated within the team .We witnessed positive relationships between people living and working at the home. There was a warm and respectful rapport between those who live and those who work at the home, and staff were seen to offer personal care in a discreet manner. Healthcare professionals indicated through surveys that were 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. Though again, all this was in the context of what they saw as low staffing levels. Individual care notes contained evidence of some good multidisciplinary work, involving a dietician, speech therapist, chiropodist, physiotherapist, dentist and others as necessary. The home asked people if they wanted to self medicate or keep their medication in their rooms, but no-one wants to do this at the moment. All staff who administer medication have undertaken training and reviews to ensure that safe practice is maintained. Discussions with staff indicate that procedures relating to the administration and recording of medicines were in line with current good practice. All medicines are stored securely. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are not always responded to promptly and sometimes people feel that their concerns are not listened to. Residents are protected by staff who know their duty to report poor practice. EVIDENCE: There is a leaflet produced by Leonard Cheshire called ‘Have Your Say’. However, this is a general leaflet and not specific to Westmead. It is also not very user friendly for the people who live at the home. A leaflet specific to Westmead and available in a variety of formats would be more accessible to people who may need to raise concerns. A complaints log is kept with some outcomes shown. However, the recordings were rather haphazard and it was difficult to see how concerns had been addressed. People indicated through discussions and surveys that generally they know who to speak with should they have concerns or complaints. However, there was some feeling that concerns don’t get addressed. Several relative surveys indicated that concerns they had raised had not been dealt with and one care manager commented on the survey form ‘Concerns are usually responded to Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 17 fairly well, but my client’s family sometimes feel they have to keep on reminding the staff members of their concern’. The temporary manager said that they were keen to address issues in a timely way, and staff and representatives indicated that there had been some progress in this area. The Commission has received no complaints or concerns about the home since the last inspection. Staff indicated through discussions and surveys that they had received training in recognising and dealing with abuse. Staff had recently received a training update in this area. Staff were able to describe differing types of abuse and were clear about their responsibility to report any suspicions. Though they felt any concerns would be dealt with appropriately they were clear about who they could report concerns to outside of the home. Two signatures are now obtained for all transactions relating to the finances of people living at the home. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 18 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, 26, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are areas of the home where the standard of décor is poor, with little evidence of regular maintenance. The home does not, therefore, present as a comfortable, safe and enabling environment for those living in, working at and visiting the home. EVIDENCE: All of those who live at the home are wheelchair users and it therefore vital that all areas of the home and grounds are accessible to them. In order to achieve this adaptations have been made, and those people who are able were seen to move independently around the home and the immediate garden area. However, the home does not present as a comfortable and homely place in which to live. The large entrance lobby was untidy and contained unused Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 19 wheelchairs, boxes waiting for collection and furniture pushed into one corner. One representative commented on their survey ‘ I am always depressed on entering Westmead …. it looks like a dumping ground for anything and everything’. The dining area downstairs is cluttered and is not a comfortable area in which to spend any length of time. As most people seem to enjoy this area and prefer it to upstairs, consideration should be given to making it more user friendly and comfortable. The upstairs dining/sitting area is more comfortable, but seldom used as a sitting area. All communal areas of the home are in need of redecoration, paint is chipped from door frames and walls, and gives the home a general shabby appearance. Individual rooms are more pleasant, have been decorated to the taste of the occupant and contained many personal items. Rooms also contain any adaptations needed to meet the needs of the individual. Some individuals now eat their meals in the upstairs dining area and this means there is more space downstairs. Lunch time was spent in the dining room chatting with people while they ate, and staff were able to move freely around the area, giving assistance where needed. Some work has been undertaken to en-suite facilities are four are now usable. However, one person cannot physically use the standard bath in their en-suite and the sixth is still out of use. Some people cannot use the call bell system available. The acting manager said that he believed that there are some infra-red sensors at the home, that would enable individuals contact staff more easily. Unfortunately he has so far been unable to locate these. The laundry facilities were clean and well organised; and contain a sluicing sink and hand washing facilities. The floor and wall finishes are impermeable and readily cleanable. A dedicated laundry worker is employed, with overseas volunteers helping out on occasion. The home was clean and tidy throughout and liquid soap, paper towels, and disposable gloves and aprons, are freely available around to the home to ensure good infection control. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 20 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): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are well trained and competent. However, staffing levels operate at a fairly minimal level, which means that while personal care needs are well met, not all individuals’ social care needs are being met. Arrangements for staff recruitment are good, ensuring that individuals are safeguarded from the risk of abuse. EVIDENCE: On the day of inspection there 14 people in the home, with three permanent staff two agency staff and 2 overseas volunteers on duty, as well as supporting staff in the kitchen and office. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 21 Staffing levels remain the same as at the last inspection, and many comments on this were received from individuals living at the home, their representatives and health and social care professionals. While everyone was generally happy with the care provided, staffing levels were seen as limiting opportunities for people to be more active and social. Many individuals indicated on their survey forms that their choices and activities were limited depending on how many staff were on duty. Similar comments were received via survey forms from representatives, staff and health and social care professionals, for example, ‘Lack of staff limit the opportunity to go out and undertake activities. Residents are unable to access the upstairs lounge due to practical constraints of moving everyone up and down in the lift and insufficient staff for supervision.’ Another comment was ‘Staffing seems to be an ongoing issue for Westmead’. A member of staff commented ‘ I love my job, but the staffing levels have reached an all time low and you feel under constant pressure all the time’. However, despite the staffing levels, good work is being undertaken and personal care needs are well met. Staff spoken with had a good understanding of the residents’ needs and preferences. Positive comments were received from residents about how good the staff were and there were several comments on survey forms that also indicated this, for example ‘Most of the staff are caring and supportive’ and ‘with the ongoing training staff do seem able to obtain the necessary skills to carry out their duties’. Staff members said that there was good training on offer, and have received training in moving and handling, fire precautions, individual service planning (care plans), infection control and health and safety. Of the 26 staff employed, 13 have already obtained a NVQ (National Vocational Qualification) and another 4 are studying to obtain one. Three staff files were inspected, one file did not contain two written references, though this staff member had only recently begun work at the home and is supervised at all times. All other required information, including, Criminal Records Bureau checks and proof of identity had been obtained for all three files. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 22 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, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not benefited from having a registered manager in post to direct the development of the service. There are some quality assurance systems within the home that enable individuals to make their views known, but these are not always acted upon. Practices within the home promote and safeguard the health, safety and welfare people living in, working at and visiting the home. EVIDENCE: Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 23 Since the last inspection the newly appointed manager has resigned. There is currently a temporary manager at the home while the post is advertised. Many comments received from people who live at the home and their representatives and staff related to the lack of a long-term manager in recent years. There was a general feeling that most of their concerns related to the lack of direction and poor management of the home. There are some quality assurance measures in place including questionnaires and regular meetings for those who live at the home. Minutes of these meetings are available and demonstrate the involvement of individuals in the running of their home. There is also some evidence of their involvement in planning some activities and meals. However, some individuals still felt that their views are not always acted upon especially in relation to the dining room, activities and staffing. The pre-inspection questionnaire provided evidence that Westmead House complies with health and safety legislation in relation to the maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. However, records would benefit from showing more detail in relation to exactly what topics had been covered during fire awareness training. Thermostatic valves deliver water at a safe temperature to all taps and water daily records are kept of bath temperatures. All radiators are either guarded or have love surface temperatures in order to minimise the risk of burning. Restrictors are fitted to all windows above ground floor level in order to minimise the risk of falls from the windows. Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 24 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 1 25 X 26 3 27 2 28 X 29 1 30 X 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 2 1 3 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 1 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 1 X X 3 X Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 25 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 YA13 YA8 Regulation 12 (3) Requirement You must ensure that the needs, wishes and preferences of individuals living at the home are taken into account when planning social and leisure activities (previous timescale of 29/09/06 not met) Timescale for action 21/09/07 2. YA24 3. YA29 24 You must ensure that 21/09/07 (2)(a)(d)(e) individuals living at the home do so in a suitable, comfortable, well decorated and well maintained environment. You must ensure that the dining area currently used, is reviewed as requested individuals living at the home and their representatives. 23 (2) (n) You must ensure that 21/09/07 individuals living at the home are able to summon assistance as required. (previous timescale of 27/10/06 not met) 18 (1) (a) You must ensure that there are sufficient numbers of suitably trained staff on duty at all times, to enable the personal and social care needs of individuals living at the home to DS0000022129.V336512.R01.S.doc 4. YA33 21/08/07 Westmead Version 5.2 Page 26 be met in a timely manner. (previous timescale of 25/08/07 not met) 5. YA39 24 You must consult with 21/08/07 individuals living at the home and their representatives on the quality of care provided at the home. You must then produce a plan that shows how their views have been acted upon, and make this plan available to them and CSCI 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 You should ensure that a suitably qualified and experienced manager is appointed as soon as possible to provide direction and leadership to the home. 2. YA37 YA37 Westmead DS0000022129.V336512.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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