Inspection on 30/06/06 for Westmead Elderly Resource Centre

This inspection was carried out on 30th 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 but made no statutory requirements on the home.

Other inspections for this house

Westmead Elderly Resource Centre 27/05/08

Westmead Elderly Resource Centre 28/01/08

Westmead Elderly Resource Centre 11/06/07

Westmead Elderly Resource Centre 06/02/07

Westmead Elderly Resource Centre 23/08/05

Westmead Elderly Resource Centre 22/03/05

Westmead Elderly Resource Centre 19/07/04

Westmead Elderly Resource Centre 02/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westmead Elderly Resource Centre 4 Tavistock Road London W11 1BA Lead Inspector Ffion Simmons Unannounced Inspection 10:15 30 June 2006 & 3rd July 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmead Elderly Resource Centre Address 4 Tavistock Road London W11 1BA 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) 020 7641 4595 020 7641 5781 Westminster City Council Ms Julia Patton Care Home 42 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (11), Old age, not falling within any other category (42) Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: The home is registered to care for up to 42 elderly residents of either gender. There are forty permanent beds and two respite beds. Of the 42 service users, the home is registered to care for seven service users with dementia and eleven service users with mental health needs. The home is owned and run by Westminster City Council and is situated in the Westbourne Park area with easy access to transport links and local amenities. The home was purpose built in the 1970’s and is a two-storey building. There is a passenger lift fitted in the home making all areas in the home accessible to residents. The home is divided into four units, and each resident has their own bedroom, and there is a range of communal areas within the home. The fees as outlined in the pre-inspection information is £528.62 per week. This fee does not include the following items: hairdressing, personal toiletries, clothing, newspapers, cigarettes, alcohol, taxis for shopping and outings, television sets in bedrooms, phone installation and hand sets, pet food and veterinary expenses, transport and storage for own furniture, repair and maintenance of own equipment and furniture, sweets, postage and extra recreation. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over two days and the inspector spent a total of 11 ¾ hours at the home. The inspector spent time talking to service users, Manager, staff and checked records and other documentation. Comment cards were received from service users, relatives/visitors and health and social care professionals. What the service does well: What has improved since the last inspection? A total of 12 requirements and 3 recommendations were set following the last inspection. The home has successfully met 8 of the 12 requirements and all recommendations have been met. Improvements were noted in the administration of medication, with the date of opening now being recorded on liquid medication and eye drops. The medication policy has been included into the medication file and steps have been taken to ensure that the picture of each service user appears on their medication administration records. Allergies were noted on some of the MAR sheets but not on all. The home has also been in contact with the PCT pharmacist for assistance and training. A copy of the report based on service users’ views was forwarded to the local office of the CSCI. Staff have received refresher training in food hygiene and staff are putting this training into practice. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 6 The Manager complied with the immediate requirement notice left at the last inspection to remove a wedge that was obstructing a fire door from closing. 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 Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,(6 not applicable) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A large percentage of service users did not have a written contract/statement of terms and conditions with the home. The needs of service users are assessed prior to being admitted to the home, but the home have been admitting service users outside of their registration category, which is in breech of the Registration Regulations. EVIDENCE: The files of four service users were checked during the inspection. Out of the four service users only one had a contract of terms and conditions of residency on their files. This issue was also reflected in the feedback received from service users, when only 18 commented that they have received a contract. It is a requirement that each service user must have a written contract/terms and conditions of residency on file. All residents admitted to the home undergo a needs assessment, which are carried out by the Care Managers. The care needs assessment was on file for the four residents case tracked. The assessment was comprehensive and included any identified risk factors and was forwarded to the home prior to Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 9 admission. The inspector noted following the inspection that a service user had been admitted to the home outside the home’s registration, which is over 65 years of age. The inspector has requested that the home formally notify the commission of the circumstances relating to the admission of the service user and what the future plans for this service user are. The home has also been asked to formally lodge an application to vary the conditions of registration and specify how they propose to meet the needs of the service user. At the last inspection in February 2006 it was noted that there had been a change in the needs of the current group of service users. The inspector was informed during the inspection that there were fourteen service users who have been formally diagnosed with dementia. Since the inspection in February two more service users have received a diagnosis, making the total number of service users with dementia to 16. The home’s current registration permits the home to care for seven service users with a diagnosis of dementia. The local authority has applied for a variation to increase the number of people with dementia who can be cared for in the home. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information relating to service users’ needs is good, but the care planning process should demonstrate the involvement of the service user wherever possible and care plans must be dated. Service users’ health care needs in some incidents are poor monitored and recorded and in some cases risks are not highlighted and managed appropriately. Some improvements were noted in the recording of medication but steps must be taken to identify know allergies and to ensure medication is stored at safe temperatures. EVIDENCE: Each of the four service users case tracked had a care plan on file outlining their needs. The care plans were adequately detailed but two of the four care plans were not dated. The inspector could not see evidence that the care plans had been completed with the service user’s involvement and that service users are satisfied with the content of their care plan. It remains a requirement that steps are taken to involve the service users and/or representative if appropriate in the care planning process and their agreement with the plan should be sought. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 11 Whilst reviewing a service user’s file, the inspector noted that the service user had been identified within the needs assessment of being at risk of social isolation and falling. The service user had fallen since being admitted to the home. No risk assessment was in place for either of the identified risks and no risk management plan was in place. The inspector also noted that another service user had not been assessed for the risk of malnutrition, that admission weight had not been recorded and that subsequent weights had not been monitored. The risk of developing a pressure sore was not assessed either for this service user. The medication was checked on two of the four units. The medication was securely stored in metal cabinets. There were no controlled drugs in use in the home at the time of the inspection. The medication administration records were well completed with no gaps noted. The date of opening is now recorded on all liquid medication as per the requirement of the last inspection. The inspector noted that a medication policy has been included into the medication file as per the recommendation of the last report. Since the last inspection, steps have been taken to ensure that the picture of each service user appears on their medication administration records. Allergies were noted on some of the MAR sheets but not on all. It remains a requirement that allergies must be noted on service users’ mediation administration records. Steps must also be taken to ensure that the room temperature where medication is stored is recorded and remains below 25°C. The Manager confirmed within the preinspection information that all care staff and Managers that are permanent employees have received training in the administration of medication. The home has also been in contact with the PCT pharmacist for assistance and training. The inspector received the following comments in a comment card “I was a bit surprised by staff talking to a service user in a childish manner and addressing them in a ear where it was documented that they had not hearing.” Staff must ensure that they treat service users with dignity and respect at all times and communicate with them appropriately. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle and activities on offer satisfies some but not all service users. One-to-one activities are limited by the current staffing levels. Service users’ views regarding the food are mixed. Improvements are needed to ensure that service users receive a wholesome and appealing balanced diet at times that is convenient to them. EVIDENCE: Approximately 30 of service user commented that there are always activities arranged by the home that they can take part in. Forty percent of the service user group commented that only sometimes there is activities arranged that they could take part in. A relative commented “there is very little activity here.. what my relative needs is to go out more”. The inspector noted some good interaction between the activity officer and service user including one-toone sessions and quiz. The inspector also observed another staff member sitting with service users and enabling them to play a game of dominos. The inspector noted however that apart from the examples given above there was little opportunity for staff to engage service users in meaningful activities and for promoting independence due to the low staffing levels. Staffing levels must improve to ensure that service users’ needs are fully met and the range of activities both within the home and outside the home must be improved to reflect the service users’ needs preferences and capabilities. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 13 One of the service users spoken with expressed dissatisfaction with the fixed routines in the home, which mainly concentrated on physical tasks. They expressed that many service users are compliant with this routine but the service user said that they didn’t want to “get sucked into the system”. The service user expressed that very little interaction between staff and service users goes on in the home. The service user expressed that they mainly communicate by telling service users to “sit there” and “have you taken your medication?” Routines in the home must be flexible and varied as far as possible to suit the individual service user. The mealtimes were observed on two of the four units. The dining tables were nicely presented with a tablecloth and flowers. Service uses were given a choice of drinks and the food was nicely presented. Mealtimes on the whole felt relaxed and unhurried and staff were encouraging and prompting service users to eat their meals. The inspector noted that jugs of juice were also available during the course of the day. The feedback from service users were mixed with regards to the food. During the inspection, the inspector noted that a service user told staff “I don’t like this type of food”. An alternative of bread and jam was given to the service user, but the inspector felt that more nutritious alternatives should have been offered. Approximately 60 of service users who completed comment cards commented that they always like the meals at the home. Some comments included “the meals are getting better”; “meals are very good and very acceptable” Approximately 25 of service users commented that they only sometimes like the meals in the home. Some of the service users commented during the inspection that they were not aware of what they had for lunch as staff “just put it in front of us without telling us what it is”. Another service users expressed that dinner is served at 5.30pm and that it is a long time before breakfast as the evening snack consists only of a couple of biscuits. Staff must offer service users a nourishing snack at supper time. A relative commented, “the quality of the food is poor, I think mostly processed”. Service user satisfaction surveys are being completed by staff as a way of observing service users’ satisfaction with regards to their meals. The results of the surveys must be collated and a copy forwarded to the CSCI and action should be taken to improve service user’s overall satisfaction with the meals. The Manager confirmed that cultural meals are offered 2-3 times per week. To promote cultural awareness and appreciation and to reflect the diversity of the client group, the home is introducing an international day. One day a month will be assigned to one country, the culture will be celebrated and service user will have the opportunity to sample the food. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users feel that they are able to go to staff if they have a complaint and that staff would listen. Policies and procedures are available for the protection of vulnerable adults, but the relevant authorities were not informed as per the policies about an incident, which recently occurred in the home. EVIDENCE: There have been no formal complaints recorded about the service. A total of 17 questionnaires were completed by service users and the majority of service users were aware of who to contact if they wished to log a complaint. The home has an adult protection policy, and a copy of the local multi-agency policy and procedure for the protection of vulnerable adults is available for staff to access. The inspector noted during the inspection that an incident occurred on the 11/05/06 involving two service users. It was documented that a staff member witnessed an incident involving two service users resulting in an injury to one service user. The inspector could not see evidence that the Adult Protection procedures had been followed. The CSCI had not been informed of the incident as per the requirements of Regulation 37 and in accordance with the multi-agency policy and procedure for the protection of vulnerable adults. An immediate requirement notice was issued outlining that all incidents and allegations of abuse must be reported as per the multi-agency policy and procedures for the protection of vulnerable adults. The immediate requirement notice also outlined the need to report the incident to the relevant Adult Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 15 Protection Team and that the CSCI is formally notified in writing of the details relating to the incident. The home was asked to also confirm that a risk assessment has been updated to reflect this area of risk. All staff must receive refresher training on the reporting of allegations and incidents of abuse. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a safe and comfortable home with access to attractive outside spaces. The home was clean and pleasant at the time of the inspection and has recently been redecorated. Although service users were consulted with regarding the décor, they were not consulted with regarding the construction of an office in their communal dinning area. Any loss in communal spaces must be compensated. EVIDENCE: The home was purposely built in 1975 and designed specifically for providing care for the elderly. The home is situated in the Westbourne Park area with easy access to transport links and local amenities, which include shops, banks, restaurants, pubs and coffee shops. The home is fitted with an intercom monitoring door system. Service users commented during the inspection that they felt safe at the home. The home has recently undergone a programme of refurbishment work, which included service users’ rooms. Service users commented that they were Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 17 involved in choosing the décor for their own rooms and one service user in particular was delighted with the work undertaken on their room. The home has two well-maintained gardens with an inner courtyard offering an attractive outside space for service users. The inner courtyard area is accessible to wheelchair users. Seating is provided outside to enable service users to enjoy the outside space. Positive comments were receive from relatives/visitors which included “Westmead House is a very good home-fromhome house and it’s a pleasure to visit this home” A new staff office has been constructed in one of the dinning areas on the ground floor. Service users were not consulted on this change and the CSCI were not informed of any structural changes to take place. The Manager has been asked to ensure that no further structural changes are undertaken without first notifying the CSCI. The communal space lost because of this construction work must be compensated and the CSCI must be formally noted on how the home proposes to do this. Laundry facilities are on site and situated away from kitchen areas. The washing machines have the required programmes for ensuring that clothes are washed at appropriate temperatures. The home was clean and tidy during both inspection days. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive care from a team of consistent, well-qualified and trained staff. Service users’ needs however are not being fully met due to insufficient staffing levels. EVIDENCE: The staffing rotas were checked. The rotas outlined that there are a total of 6 staff on the early shift, four staff on the late shift and three staff on the night shift. As previously discussed, there are a total of 16 service users who have a diagnosis of dementia. The staffing levels are insufficient for meeting the needs of the client group and must be reviewed further. The questionnaire completed by the Registered Manager confirmed that there are 22 staff members who are qualified to NVQ level 2 or above. This figure equates to a total of 85 of care staff being qualified to NVQ level 2 or above and is a very good achievement. The personal files of four staff members were seen during the inspection. Thorough recruitment procedures are in operation with checks seen to have been completed on staff, which include past work history, references and CRB/POVA checks. A probation period is offered to new staff with reviews taking place following 3 months and 5 months in post. All new staff members follow a programme of induction, which is equivalent to the skills for care induction programme. Staff are also inducted into the local policies and procedures of the home. The staff team including domestic and Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 19 catering staff are currently undergoing training in dementia care developed by the Alzheimer’s Society. Future planned training includes mental health training for all staff. Positive comments were received in comment cards about staff and included “staff team have been there for a long time generally with addition of new manager and new carers. Very helpful and caring staff.” A comment card was received however which did not reflect so positively “I was a bit surprised by staff talking to a service user in a childish manner and addressing them in an ear where it was documented that they had no hearing.” Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a competent and experienced person. Quality assurance systems are in place, securing the views of service users. The systems for safeguarding service users’ money are robust. The health and safety records are well maintained. Steps must be taken to ensure that the recommendations highlighted by the fire officer are met and that all incidents, which fall under regulation 37, are reported to the CSCI. EVIDENCE: The home is managed by a competent and experienced person, and has undergone the process of registration with the CSCI. The Manager is a Registered Nurse and has good experience of working with older people including people with dementia both in the community and in acute hospital setting. The inspector found the Manager to be open, honest and friendly during the inspection process. One service user commented “new manager here is very nice –a lady who has always made time to listen when I’ve wished Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 21 to speak to her. The duty managers are also nice and so are the staff”. Relatives/visitors also commented on the management and included the following comments “managers are very helpful and always welcoming”. The home has quality assurance systems in place including the use of service user satisfaction questionnaires. A report is compiled based on the information received within the questionnaires. A copy of the last report was forwarded to the local office of the CSCI. Monthly visits on behalf of the registered provider are completed and the reports are forwarded to the CSCI. The reports provide a good level of information. The home holds money for fifteen service users for safekeeping. The money is securely stored in a lockable safe. Systems are in place for recording any money transactions and receipts maintained and signatures obtained. The financial records and balances of five service users were checked during the inspection and were found to be correct. The health and safety documentation was checked during the inspection. The documentation was up-to-date and accurate and reflected that weekly fire alarm tests and water temperatures are completed. The home’s gas certificate was valid and a certificate was in place as evidence that emergency lighting and fire equipment have recently been checked. Currently, nine staff have been trained in first aid. Since the last inspection, staff have received refresher training in food hygiene and are now wearing protective clothing for serving food to service users. The inspector noted that a recent visit had been undertaken by a fire officer from the London Fire and Emergency Planning Authority. The fire officer made some recommendations, which the home are taking steps to meet and must ensure full compliance by the timescale given by the fire officer. As previously discussed, the CSCI was not informed of an incident involving two service users which resulted in an injury to a service user. All incidents which fall under regulation 37 must be forwarded to the local office of the CSCI without delay. Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Timescale for action The Manager must ensure that 01/10/06 each service user have a written contract/terms and conditions of residency on file. The home must formally notify 08/08/06 the commission of the circumstances relating to the admission of the service user under the age of 65 and what the future plans for this service user are. The home must also formally lodge an application to vary the conditions of registration and specify how they propose to meet the needs of the service user. The service users’ care plan 01/09/06 must be dated. Steps must be taken to involve 01/10/06 the service users and/or representative if appropriate in the care planning process and their agreement with the plan should be sought. Original timescales of 01/05/06 not me, this is a repeat requirement. DS0000036658.V301449.R01.S.doc Version 5.2 Page 24 Requirement 2 OP4 Registration Regulations 2001 12 [1] Care Standards Act 2000 15 [1]. 3 4 OP7 OP7 15 12 [3] 15 Westmead Elderly Resource Centre 5 OP8 13 [4] 6 OP8 13 [4] 7 OP8 13 [4] 8 OP9 13 [2] 9 OP10 12 [4] [5] Appropriate interventions must be in place for those identified of being at risk of falling. Risk assessments and risk management plans must be drawn up and regularly updated. The risk of service users developing pressure sores must be assessed by a person trained to do so. Nutritional screening must be undertaken on admission and the service users’ weights must be monitored on a monthly basis or more frequently should they be identified of being at risk. Any known allergies must be noted on the service users drug charts. Original timescale of 30/09/05 not met this requirement is being repeated for the second time. Staff must ensure that they treat service users with dignity and respect at all times and communicate with them appropriately. The Manager must ensure that routines in the home are flexible and varied to suit the individual service user. The range of activities on offer both within the home and outside the home must be improved to suit the service users’ needs, preferences and capacities. The results of the food satisfaction surveys must be collated and a copy forwarded to the CSCI. Action should be taken to improve service user’s overall satisfaction with the meals. Steps must be taken to ensure DS0000036658.V301449.R01.S.doc 01/09/06 01/09/06 01/09/06 01/09/06 01/10/06 10 OP12 12 01/10/06 11 OP12 16 [2] (m) (n) 01/10/06 12 OP15 24 [1][2][3] 01/10/06 13 OP15 16 [2] (i) 01/09/06 Page 25 Westmead Elderly Resource Centre Version 5.2 14 OP15 16 [2] (i) 15 OP18 13 [6] 37 16 OP18 13 [6] that service users are offered an alternative choice of meals to ensure that their nutritional needs are met. This is a repeat requirement The manager must ensure that 01/09/06 service users are offered a nourishing snack of their choice at supper time. The Manager must ensure that 03/07/06 all incidents and allegations of abuse are reported as per the multi-agency policy and procedures for the protection of vulnerable adults. Immediate requirement The Manager must ensure that 03/07/06 the incident discussed on the day of the inspection is reported to the relevant Adult Protection Team and that the CSCI is formally notified in writing of the details relating to the incident. The Manager must confirm that a risk assessment has been updated to reflect this area of risk. Immediate requirement All staff must receive refresher 01/10/06 training on the reporting of allegations and incidents of abuse. Steps must be taken to ensure 03/08/06 that the room temperature where medication is stored is recorded daily and that the temperature remains below 25°C. The Manager must ensure that 15/08/06 no further structural changes are undertaken within the home without first notifying the CSCI. The communal space lost because of this construction work must be compensated and the CSCI must be formally noted DS0000036658.V301449.R01.S.doc Version 5.2 Page 26 17 OP18 13 [6] 18 OP9 13 [2] 19 OP20 23 [2] Westmead Elderly Resource Centre on how the home proposes to do this. 20 OP27 18 [1] The staffing levels in the home 01/10/06 must be reviewed and increased to reflect the increased needs of the service users and to promote service users’ independence and flexible routines. The Commission must be given 03/07/06 notice without delay of those situations which fall under regulation 37. The Manager must ensure full 21/08/06 compliance with the recommendations of the fire officer by the timescale given. 21 OP38 37 22 OP38 23 [4] RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westmead Elderly Resource Centre DS0000036658.V301449.R01.S.doc Version 5.2 Page 28 - 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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