Inspection on 27/02/07 for Westoe Grange

This inspection was carried out on 27th February 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 but made no statutory requirements on the home.

Other inspections for this house

Westoe Grange 27/01/06

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westoe Grange 4 Horsley Hill Road South Shields Tyne and Wear NE33 3DY Lead Inspector Steve Tuck Unannounced Inspection 11:00 27 February, 13 and 22 March 2007 th th nd 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 Westoe Grange DS0000064791.V330272.R02.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. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westoe Grange Address 4 Horsley Hill Road South Shields Tyne and Wear NE33 3DY 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) 0191 4558691 F/P Mr Trevor Nesbit Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (40), of places Physical disability (1), Physical disability over 65 years of age (5), Sensory Impairment over 65 years of age (3) Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: Westoe Grange is a purpose-built care home that is close to the centre of South Shields and a number of local amenities. The home is a 3 storey building with service areas on the lower ground floor. The building provides 40 single bedrooms for service users which are on the ground and first floors with all bedrooms having a toilet and sink en-suite. There are 2 main lounges, a dining room and a conservatory. The home has a small garden area, which provides a pleasant area for service users to sit in better weather. There is a car park spaces at the front of the building including disabled parking near the entrance. There is easy access into building through the main doors into the reception area. Westoe Grange is a short walking distance from town centre shops and amenities. There is access to local transport directly outside the building. The home is registered to provide personal care for up to 40 older people, including a small number of places for older people with physical, dementia care or sensory needs. The home is not registered to provide nursing care. A place at this home costs £365 per week. Additional charges are made for toiletries, newspapers / magazines, and hairdressing. Items which are included in the cost are listed in the homes terms and conditions. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took three days, which included three site visits of about sixteen hours in total. The inspection was planned in advance but unannounced so that the manager and staff at the home did not know that it was to take place, The inspection looked at how good the home is at meeting the key National Minimum Standards and how the homes work effects the outcomes for people who live there. The inspector spent time talking to a number of the people who live at the home as well as the manager, deputy and staff. He watched the way that care staff carried out their work and joined service users for lunch. Some of the records that staff and the manager use were looked at including care plans and staff duty rotas. The inspector looked around the home and grounds, which included all areas that people use together with some service users’ bedrooms. Discussion also took place with visitors to the home and several relatives have given their views. Before the inspection took place the manager was asked to fill in a questionnaire, which gave lots of information about the way that she organises the home. These details were then checked during the inspection. All service users were also sent a questionnaire so that they could give their views. Thirteen people gave feedback about the home. These outlined key areas where service users thought the home was good or excellent and also areas which service users found less satisfactory. These are some of the things they said. “I think the care and support are excellent.” “Staff are always available to listen” “I feel very happy with all the aspects of the home and have total confidence in my mother being looked after there.” Other comments have been included in the rest of this report and have been used to make judgements about how the service is performing. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 6 What the service does well: People who move to the home have their needs assessed in detail by social or healthcare workers and the acting manager so that everyone is sure that this is the right place for them to live. The building provides good-sized accommodation for the people who live there. Bedrooms have enough space and include their own toilets. Many bedrooms been personalised by the people who live in them. There are several dining and sitting rooms that are comfortable and give variety for service users. All rooms have views over the grounds or local area. The home has bathrooms which have adaptations to help people who have difficulty accessing them. Maintenance continues to take place to make sure that the home stays in good condition. Staff training is good with almost 90 staff having achieved NVQ level 2 or 3 so they are trained to support people in the right way. Few staff have left the home in the last six months so staff and service users know each other well and there is a good atmosphere where service users and staff share jokes and experiences. Service users and relatives are able to tell the owner what they think about how the home is run which helps them to have control over their lives. All service users are able to choose the food that they would like to eat which is made from fresh wholesome ingredients by talented catering staff. So that all service users can have a healthy, well-balanced and interesting diet. Staff are very respectful and courteous to the people who live at the home. All bedroom doors are lockable by service users and service users described how their privacy is respected during their stay. Relatives and other visitors are encouraged to call in and take part in activities. All of which makes a good welcoming atmosphere at the home. One visitor said “It’s a busy place here, people are always coming and going and its nice to see so many visitors in the home.” A service user said, “ I don’t have any visitors myself so its nice when visitors come round as you get to meet people and make friends.” All service users living at the home have require support which is provided by staff without prejudice to their level of need, preference or background and their individual preferences or beliefs are respected and supported by the manager and staff. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 7 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. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 8 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 Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user’s needs are assessed before they move to the home. This helps to make sure that their needs can be met at the home and inappropriate admissions are avoided. EVIDENCE: Each service user’s needs are assessed before they move to the home either by a local authority social worker, the acting manager, or by both. This is so that the manager can be sure that the home is suitable for meeting the needs of people who are going to live there. The acting manager also finds out the cultural and lifestyle needs of people who wish to move to the home to make sure that these can be met. As a result of these measures, all of the people living at the home at present have been properly placed and the home is able to meet their needs. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 10 The home does not provide care for those people who have been admitted on a short-term basis to get special therapy while they recover from injury or hospital treatment. No one has been admitted to the home with these needs Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has an individual care plan, which should set out their preferences and how their assessed needs will be met. But these do not fully describe the measures which staff use to support service users therefore making it difficult for staff to consistently meet their needs. Peoples’ health care needs are generally met by the home which helps service users to remain as active and independent as they can. The way that staff at the home store and give out medication helps to make sure that service users receive the medical treatment they have been prescribed and mistakes are avoided. Service users feel that they are treated with respect and their privacy is upheld which helps them to stay confident and empowered. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 12 EVIDENCE: Staff organise and write down how they support people at the home in care plans. These should state each service user’s physical, emotional and lifestyle needs and the ways that staff are to meet these. Staff are encouraged by the acting manager to write significant events or monitoring observations into care plans. However, some people did not have plans in place to support all of their needs and for others the care plans did not match the actual support and intervention that staff currently carry out. Staff have a variety of knowledge and experience of caring for service users at the home but this information is not yet successfully combined in the care plans so that these can be used to consistently provide co-ordinated care. All of the staff interviewed could describe the needs of service users in depth, their needs, preferences and histories, however the potential areas of good practice were not generally shared with colleagues nor were these recorded in the care plan. The home is registered to provide care to three people who have dementia. Care planning arrangements for these people do not yet reflect current best practice. For example, care plans do not specify how people who have an altered sense of time or reality are to be supported or what their personal timescales actually are. Care plans, which place the person at the centre of a network of support for their needs and lifestyle requirements, are yet to be put in place. This can be particularly important for service users who may become increasingly reliant on staff as their level of dependency increases. The health of service users is monitored and supported so that people get the treatment they need. Service users needs are reviewed by staff and any worsening in health is noted so that treatment can be arranged quickly. Staff are diligent and routinely involve Doctors and community nursing staff. For example the observation of skin conditions and the treatment of pressure sores. But the weight of service users who are unable to stand is not monitored to make sure that they have an appropriate diet or have become unwell. Due to their levels of need, most service users are not able to organise their own medicines, and appointed staff therefore help in this area. Staff at the home have been trained so that they can take responsibility for medication. Medication is securely stored and records were accurate showing that service users had received the correct medication. Service users are treated with respect by staff who know them well. Relationships between service users and with staff are relaxed, friendly and informal which helps people to feel comfortable. Staff were observed to treat Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 13 service users who took part in discussions with respect and one service user described staff “Nothing is too much bother to a caring staff.” When asked, staff talked about service users’ needs in a sensitive and respectful way. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported by the staff to lead fulfilling lives with their rights as individuals being respected. Contact with family members and friends are supported where possible so that service users keep links outside of the home. The meals provided offers an interesting balanced diet which helps service users to eat healthily and supports their physical and emotional wellbeing; and service users and families are involved in planning the menu so they can say what they would like to eat. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 15 EVIDENCE: Service users talked of the things that they do both inside and out of the home, in the local and wider community. For example games sessions, shopping visits, social events and entertainment. Some people live very independent lives at the home, and because the facilities of the town are very close, they can spend time using these facilities or visiting friends or family. There are photographs of celebrations and events and service users talked about these. For some of the people who are unable or do not wish to leave the building there is a range of activities taking place some of which have been suggested by service users and an activities co-ordinator has been appointed to increase these opportunities. Activities include, singing lessons, entertainers, exercise sessions and Gardening. There were several visitors to the home, all of whom appeared comfortable with the environment and staff. Service users are encouraged to make choices about their diet. Most people said that they like the meals at the home and that they are asked what they would like to eat. Staff were observed asking service users about their choice of meal, size of portion to make sure that service users can make choices about what they eat. Staff were available during meals to offer support and assistance where needed and this makes meal times a relaxed and unhurried experience for service users. Menus were available which confirmed that a range of meals are provided which give service users a balanced diet and refreshments are available throughout the day and night. A range of fresh fruit and vegetables are used in the preparation of food at the home which increases the nutritional benefit for service users. Service users and their families are involved in choosing the meals that are included in the menu. Meals are prepared by a competent chef who is keen to focus the menus and style of cooking on the nutritional needs and lifestyle preferences of service users. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system which service users can use if they are unhappy, have a grievance or dispute. They also give feedback when they are happy with the service. This helps them to have control over their lives and shows that their views are valued. The home has measures in place which protect service users from being harmed which helps to promote their safety and security. EVIDENCE: There is a clear procedure in place at the home which tells people how to complain and the length of time a response will take. Observations of the manager and staff’s day-to-day practices show that they ask for the views of service users and promote choice and decision-making. Some service users and relatives have made complaints and these have been dealt with by the acting manager in accordance with the homes procedures. In discussions service users and their visitors said that they would feel comfortable about approaching senior staff if they had any concerns, and were confident that these would be dealt with. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 17 The home has an adult protection procedure which is robust and complies with the Public Disclosure Act and the Department of Health Guidance. Information about the role of the local authority is available and included in the homes procedures. All staff spoken to are knowledgeable of these procedures. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 21 22 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable, pleasant and hygienic and well maintained so service users can be confident that the good standards of accommodation will continue to be provided. Aids and adaptations have been provided to promote service users’ independence and safety. But they cannot control the temperature of their bedrooms which does not suit some people. EVIDENCE: All communal areas and some service users bedrooms were viewed during the inspection. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 19 The home has been purpose built so that all service users can have safe access to the areas of the home in which they live. Service users are able to lock their bedroom doors so that they can have privacy and there are areas where people can meet in private. However the temperature of some bedrooms is not easily controlled by service users and one person said that their room was too warm. All service users have individual bedrooms most of which have been furnished with personal items to make them individual and homely. Some people have brought their own furniture with them about which one person said “You spend all your life with these things around you so it’s nice that you can keep them with you when you move into a home.” The home is kept clean by staff who take steps make sure that there are no unpleasant smells. There has been recent ongoing repairs, repainting and redecoration, and there is an ongoing plan of maintenance and major renewals. All maintenance and redecoration has been carried out to a good professional standard with excellent levels of finish creating a comfortable environment which is appreciated by service users. There are adaptations around the home so that people are able to use the facilities more easily. For example, bathrooms have a hoist which is to help people to get in and out of the bath more easily. Laundry facilities are properly maintained so that they don’t break down unexpectedly and run to make sure that all laundry is hygienically cleaned. Laundry is well organised to minimise mistakes and make sure that peoples clothes are not lost. Since the last inspection the smoking areas in the home have been changed to protect the health of service users, visitors and staff and make the home a more pleasant environment. Only service users are allowed to smoke and sensitive arrangements have been put in place to accommodate them. The home is also inspected by the Fire Prevention Service and overseen the local authority to make sure that risks from an accidental fire are lessened and a safe and healthy environment is promoted for service users and staff. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. There are sufficient staff working at the home to meet the needs of people who live there. Many of the staff have undertaken training to make sure that their care practice is good and the acting manager guides them to make sure that they support people properly. The ways that staff are employed is not robust and does not make sure that service users are protected from people who are unsuitable to work with vulnerable people. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 21 EVIDENCE: The acting manager has organised the home so that there are sufficient staff available to meet the needs of service users who currently live there. Rotas, which organise when staff are working are well structured and arrangements are in place should staff need to take leave at short notice. The acting manager has spent time working with staff and has been careful to make sure that there are enough personnel available to meet their assessed needs. Staff are supportive of each other and their manager, both in their practice and also in their willingness to remain flexible about their work arrangements so that service users will benefit. Staff were noted to spend quality time with service users, listening to their opinions and experiences and taking part in. Not many staff have left the home which gives service users and staff the opportunity to get to know each other and helps the acting manager to structure and train her team. Almost 90 of the staff team have now attained NVQ awards in care at level 2 or above, the remainder are all working towards either Level 2 or 3. But where new staff have been employed, a specific programme of induction training within the first weeks of their employment has not been carried out. The acting manager makes deliberate attempts to recruit staff from similar cultural backgrounds as the service users living at the home. In some cases service users and staff share the same community and social links which helps to ensure that service users are confident with the way in which they are supported. The acting manager routinely employs staff who have not had a full Criminal Records Bureau check carried out. Whilst it is acceptable to recruit in this way in exceptional circumstances, for example where staff shortages unexpectedly occur, staff must be checked against the ‘POVA First’ list and have all other pre employment checks carried out before they can work at the home. The acting manager keeps records which show that staff have been employed without a full CRB as a matter of routine employment practice. However records show that one member of staff was employed at the home for a period of four days without a ‘POVA First’ list check having been carried out. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager provides commitment, leadership and direction to the staff so that they can meet the needs of service users. The views of service users and their families are taken into consideration when planning how the home is to be run so that people living there can have their say. Service users financial interests are safeguarded but they are not given information about their payments which would help them to stay in control of their spending. Staff get supervision from the acting manager or senior staff to make sure that they carry out their role effectively and that their care practice meets the Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 23 needs of service users. Arrangements to make sure that the health safety and welfare of service users and staff are in place and are usually successful. EVIDENCE: There has been a new manager appointed at the home since the last Key Inspection who has not yet been assessed by the Commission to see if she has the skills and qualities to be fit to become registered as the manager of this home. The manger does have several years experience in a variety of care roles. She has began to make changes at this home in the time she has worked there as acting manager which has helped to improve the quality of the service. The views of service users, families and friends are collected and checked to see if the service is meeting the needs and expectations of all parties. There are also meetings held at the home where the acting manager is able to check that people are satisfied with the service. This helps her to make management plans, monitor progress and develop the service. Satisfactory insurance and public liability cover is in place to protect the service, its staff, the people who stay there, and visitors. The home helps most service users to manage their day-to-day spending and accurate records are kept of these transactions which match the amounts of finances held. Arrangements for the home to keep service users valuables are carried out with diligence. However service users do not currently receive individual notification that their payments for fees have been received by the home which makes it difficult for them or their relatives or representatives to keep control of their finances and to check that these are correct. The acting manager has made sure that formal one to one supervision takes place with each member of staff at least six times per year. This gives the acting manager the opportunity to analyse the strengths and needs of staff and help to develop their working skills. There were no noticeable hazards at the home throughout the inspection and arrangements are in place to minimise risks for service users and staff. However staff had not received sufficient training about the actions that they must take in the event of a fire at the home. The home has been subject to inspections by the Fire Authority and local authority environmental health officers to make sure that it home is safe. Westoe Grange DS0000064791.V330272.R02.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 2 Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement The responsible individual must make sure that care plans are sufficiently detailed to guide staff practice in meeting service users care and lifestyle needs and record the work they currently undertake. The responsible individual must make sure that all support for people with dementia follows current best practice and this is recorded in each persons care plan. The responsible individual must make sure that nutritional screening is carried out for individual service users and appropriate healthcare advice is sought where required. The responsible individual must make sure that all staff have appropriate pre employment checks carried out before they begin working at the home and shortcuts are only used in exceptional circumstances. The responsible individual must make sure that staff have ‘Induction’ training within the DS0000064791.V330272.R02.S.doc Timescale for action 01/07/07 2 OP7 12 01/07/07 3 OP8 12 01/05/07 4 OP29 19 25/04/07 5 OP30 18 25/05/07 Westoe Grange Version 5.2 Page 26 6 OP31 9 7 OP35 17 8 OP38 23 first six weeks of starting work at the home. The responsible individual must 01/07/09 make sure that the home has a manager who has been assessed by the Commission to make sure they are fit to be in charge of the home. The responsible individual must 25/05/07 make sure that detailed information about the payments for fees that service users have made to the home are individually recorded and routinely forwarded to them. The responsible individual must 10/05/07 make sure that all staff have sufficient instruction about the actions they must take in the event of a fire at the home. 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 OP25 Good Practice Recommendations The responsible individual should make sure that the temperature of service users bedrooms can be more effectively changed to meet their preferences. Westoe Grange DS0000064791.V330272.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Westoe Grange DS0000064791.V330272.R02.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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