Inspection on 17/11/06 for Weston House

This inspection was carried out on 17th November 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Weston House 17/10/08

Weston House 25/11/05

Weston House 18/05/05

Weston House 01/12/04

Weston House 22/09/04

Weston House 03/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Weston House 344 Weston Road Weston Coyney Stoke-on-Trent Staffordshire ST3 6HD Lead Inspector Key Unannounced Inspection 17 November 2006 09:00 Weston House DS0000008258.V320307.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 Weston House DS0000008258.V320307.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. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weston House Address 344 Weston Road Weston Coyney Stoke-on-Trent Staffordshire ST3 6HD 01782 343818 01782 322588 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) Groundstyle Limited Miss Maria Wright Care Home 28 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (28), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (9) Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 12 MD - 5 may be under 55 years Date of last inspection Brief Description of the Service: Weston House is a large detached property situated on a bus route near to Meir and Longton town centres. It provides accommodation presently for up to 28 adults. The home was acquired by the present owners 4 years ago and considerable improvements have been made to the environment since that time and extensive upgrading both internally and externally. This work continues. At this time plans being submitted to add conservatory, reception/office area and upgrade toilet/bathroom areas. The home have moved sensitively from care for the elderly towards care of younger with mental health needs. Presently there are only 4 people over the age of 65 years. The home continues to provide care for older people who are accommodated on ground floor area. .Access to a range of primary health care services is provided for all residents. Specialist health care staff are involved in care provision e.g. Psychiatrists, Psychologists, CPNs. An Activities Worker is employed 30 hours per week with flexible working hours to promote access to the community and provide a wide range of internal and external activities on an individual or small group basis for all residents. This is successful, has been operating for the past 2 years and provides an excellent facility for this resident group. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced inspection there were 24 people in residence. Only 4 people are over 65 years of age. Eight residents have physical and mental health needs relating to alcohol abuse. Fees for residents at Weston House are £347 - £499 per week. Most residents were seen and the majority spoken to separately and together. Two asked to speak to the inspector specifically. The Manager and 7 staff on duty were seen and spoken with. There was an inspection the physical environment including a sample of bedrooms. Care planning information, staff records, medication and fire records were seen and other information relative to the inspection process. The Providers continue to make significant improvements to the environment and further plans to build extension and conservatory. Four additional bedrooms will be provided and provision of shower facilities and upgrading of the bathroom/toilet areas. The home have successfully moved from providing care for older people 4 years ago to providing care for people in the younger age range with mental health needs. The care provided is to a high standard. Six residents provided written feedback to the Commission there were many positive statements about care. One said “I enjoy what we do, I enjoy the outings very much” - summarising the excellent activities programme in place. Two residents spoke to the inspector of their concerns about lack of hot water supply to bedroom, inadequate toileting facilities on the first floor (this was also referred to in written feedback to the Commission) and request for carpeting of bedroom to replace laminate flooring. These matters were discussed with the Manager and requirements made in this report. Two relatives sent written feedback to the Commission both expressing satisfaction with care. One said “ The staff are always friendly, my sister is settled and happy in the home”. The husband of a recently admitted resident summarised the service for new residents in saying he was “amazed at the reception (his wife) was given when admitted, there was tea upon arrival and flowers to welcome her. Staff are wonderful to us both. It feels like coming home, they call us by our Christian names. When I have visited I go to the car and cry, because I am so relieved that she is safe and well cared for”. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 7 Self-medication must be subject to risk assessment, known to and monitored by staff. Fire drills should include all residents and plans for evacuation of the premises in the event of fire reviewed. Check that all fire doors close onto door rebates to ensure protection in the event of fire. The toileting facilities on the first floor must be improved. CSCI must be informed when the bathroom currently out of use is in operation again. Hot water should be available in residents bedrooms at all times. 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. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 8 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 Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Pre-admission procedures and assessments are in place and good. All prospective residents spend time in the home prior to admission. EVIDENCE: There is a statement of purpose/service users guide in place and available in the home for residents and relatives. There is adequate information available to make and informed choice about the suitability of the home. The homes capacity to meet need is defined in the statement of purpose. There is a good staff training programme and all staff have the opportunity to study NVQ. A range of specialist services for people with mental health needs, are provided to the home by the Health Trust. Records relating to recently admitted residents were seen and they were spoken to. In one instance the person had been in hospital but came to the home with her family prior to admission, had lunch and met residents and staff. She made her decision about admission. Her personal effects were Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 10 brought from home prior to her admission and placed in her bedroom, she was welcomed upon admission with a bunch of flowers. In both instances pre-admission assessments were seen having been carried out by the Manager prior to the admissions. Each person had received a letter from the home prior to admission stating that their needs could be met. A Care Management Assessment had been provided in both instances. In relation to a person admitted 6 months ago a contract had not been provided by the Local Authority although requested many times. No personal allowance had been given and the resident was effectively “borrowing” money from the home to finance daily living e.g. cigarettes, outings etc. A total of £12,000 was owing to the home. The reason for this was - there had been no financial assessment completed by the admitting social worker. Records and correspondence confirmed that the home had done all they could to secure payments for fees and personal spending. At the time of this inspection there appeared a definite prospect of the situation being resolved with benefits brought into payment etc. Although there had been the stated problems concerning finance a review had taken place 6 weeks after the admission to discuss and confirm the suitability of the placement. The resident was quite happy with his care and wished to live at Weston House permanently. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning information has been improved and is now satisfactory. There are opportunities for residents to influence decision making and they are encouraged to participate in all aspects of life in and outside the home. EVIDENCE: Care plans for recently admitted residents were inspected. Information was based upon the pre-admission assessment by the home and the Care Management Assessment. The information in care plans has been improved over the past year with some plans re-written. Records relating to a person admitted the previous week contained all required information including social and medical history and all information required to provide care. There had been a review of medication with the GP 5 days after admission. Daily notes were detailed and gave a clear account of the settling in process. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 12 Care plans including risk assessments are reviewed on a monthly basis in the home. Many are subject to statutory aftercare under the Mental Health Act and reviewed as required on a 6 monthly basis. Residents are involved in care planning and encouraged to sign plans. Those seen had been signed by the resident. Risk assessments were in place covering all resident activity. Any restrictions are known to residents and recorded in care plans. Care plans are kept in the office area of the home where residents can access them, but are secure. Residents are able to freely express their wishes and views. There is a regular monthly residents meeting which is documented. They are consulted about food, activities in the home and matters affecting the daily running of the home and their lives. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Chosen lifestyles are known, respected and accommodated. Activities provision is excellent in this home and caters for the diverse resident need. – A high quality of life is the bi-product. There is a history of high satisfaction with food. EVIDENCE: This home provides an excellent range of activities both inside and outside the home. The Activity Worker works 30 hours per week in the home and leads on activities, which all staff are involved with. Activities are arranged during the day, evenings and weekends to provide stimulation and occupation throughout the week. Many staff are involved in evening and weekend social activities with residents in the community although they are off duty. This includes all staff, managers and their families. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 14 There is an activity programme posted in the home, the current monthly list includes: Ladies afternoon with cream tea and manicure. German theme night – meal with social entertainment. Star Night Out – Meal Elvis Presley (theatre). Christmas party bookings for all residents, staff, managers, relatives and friends. This programme is ongoing and apart from the major external events there are ongoing daily activities provided with the usual games, karaoke etc. and 1:1 engagement with residents who have difficulty with small group activity. There are daily outings to shops, pubs, restaurants etc. One resident who refuses to go out recently expressed an interest in shopping, the opportunity seized as it presented, he was taken shopping to the town and this has subsequently been repeated. A resident with a background of interest in fishing was taken fishing by the activities worker. The activity is clearly just a vehicle for socialisation and integrating residents in the community – social inclusion. There are many day trips to local venues and Blackpool recently by resident demand. The stories continue long after the event. A party of people went to Venice earlier in the year (suggested by residents) the photographs displayed showing residents in gondola recorded the enjoyment and the interest and talking point about the event continues months later. This is a very necessary and extremely positive aspect the care provided in this home. It is promoted extremely well and includes all residents, regardless of their restricted capacity due to mental health needs, at a particular time. The social and therapeutic benefits are enormous and vastly improve functioning and quality of life. A resident admitted a week ago and who has memory loss, has enjoyed the Ladies Afternoon and looking forward to the other activities. She has a background of interest in gardening and this has been noted by the activity worker and will be appropriately channelled. Residents are able to make choices about lifestyles. Some engage in most activities, others prefer less involvement. There is no pressure, only encouragement to be involved. Some residents were seen spending a large part of the day in their bedrooms – for varying reasons. One enjoys crafts, making greeting cards etc. and likes to be occupied but involved in social activities when she chooses, she has all meals served in her bedroom. Another resident spends most of his day in his bedroom. This is due to his psychological state and a pre-occupation with his memory loss and feelings about loss of family etc. He is encouraged to use the dining room, and involves himself in occasional activities of his choice. Staff understand that due to psychological and illness-related behaviours it is important to proceed at the residents pace. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 15 Food provision is reported to be good. There have been no complaints about food and residents are involved in menu preparation and choice. Most people complain that they “eat too much”. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Personal and health-care support is given to meet the needs of residents. Residents physical and emotional health needs are met. Treatment of wounds must remain the responsibility of the District Nursing Service. Urgent review of arrangements for self-medication by resident is required. EVIDENCE: The remaining small number of older residents require some input with personal care provision and some of the younger residents with a physical disability. Many require oversight or support in person hygiene maintenance. The majority of residents have enduring mental health needs. Eight of those have alcohol related illnesses and require a higher level of care. Staff have a history of heightened awareness of health care needs both physical and in situations where mental health needs may change. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 17 Most residents attend the local health centres and GP surgery nearby for the usual services offered. Staff support is given if needed. Some home visits to older residents are made by GP’s as required. The District Nursing service provide a visiting service where necessary. Currently they are visiting 3 residents: One with heel ulcer who is diabetic, a resident with oedema and one with a leg ulcer. The nursing notes were seen relating to the leg ulcer, the wound was described at one point as necrotic, clearly a significant wound requiring regular dressings. Care staff were required to wash his legs in Epiderm apply a cream and change dressings upon occasions, mainly when the district nurse was unable to visit. The Manager is unhappy about the pressure for her staff to provide this service and she was advised that care staff should not be carrying out these functions, which are the responsibility of the nursing service. This practice should cease. There are 5 people who suffer from epilepsy all are tablet/diet controlled. Insulin was previously administered by care staff with a pen under the oversight of the nursing service, after appropriate training. This is no longer administered. The medication system was inspected. A requirement of the last report to provide a count of medication and record the dose given when variable dose medication was used, has been put into place. It became clear on this visit that a resident who has been cared for on a short stay basis (which has now extended to 18 months) self medicates. Her medication is collected from the pharmacy by the family and given directly to her. The home are unaware of the medication being prescribed, dose given etc. The home has responsibility in this matter as part of their duty of care to know the details of prescribed medication and have responsibility for its safe administration to the resident. A risk assessment must always be completed for residents who wish to self medicate. This has not been done. It is a requirement of this report that this issue is discussed with the resident and relative and written agreement reached. A risk assessment must be carried out for self-administration of medication in full knowledge of the medication prescribed. The arrangements for the receipt, storage and self administration must be recorded. Arrangements for monitoring the medication must be agreed in writing. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards relating to concerns, complaints and protection were found to be met. EVIDENCE: A complaints procedure is posted in the home for resident and visitor use. The procedure complies with Regulation 22. No complaints have been received by the home or the Commission since the last inspection. There is a policy/procedure relating to abuse and written instructions for staff concerning the reporting of suspected or actual abuse. There is a copy of the vulnerable adults procedures in the home also. One resident in feedback did say that he knew who to speak to if he was not happy but said “I cant always speak to the Manger because she is a busy lady”. The Manager in this home operates “hands-on” rather than remotely from an office. She says that she spends time each day in the lounge areas with residents and ensures that she speaks to all residents at some point in the day. This was confirmed by residents in discussions with the inspector. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There have been, and continue to be vast improvements to the environment. Further complaints relating to inadequate hot water supply to bedrooms and the provision of adequate toilet facilities must be addressed. EVIDENCE: There have been extensive improvements to all parts of the building over the past 4 years both internally and externally the results are very impressive. There is an annual development plan - a copy is given to the Commission. All planned work to September 2006 has been completed and the providers have produced a further plan for the year to August 2007. The plan includes building and environmental development and is extensive. There are plans to build and create 4 additional single bedrooms, build a conservatory and refurbish and create further bathroom/shower/toilet areas and reduce the number of shared bedrooms. Replacement of all windows and existing furniture. Plans for the major work are currently being processed. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 20 The record of the providers in making improvements to this home have been excellent and clearly it is intended that this will continue. Many areas in the home have been improved. Since the last inspection all new beds have been purchased and most had new furniture. Some bedroom have been re-decorated and new bedding/curtains purchased. There are 3 double bedrooms 2 identified in the last report requiring improvement. This has been done and the presentation of those rooms improved. Privacy curtains have also been fitted as required. These rooms were also required to have at least 2 comfortable chairs and they have been provided. Two residents with self-propelled wheelchairs were admitted out of category. The location of their bedrooms presented some issues concerning fire safety, which were referred to the Fire Officer. Both residents are now located nearer to the lounge and toilet facilities. No further admissions must take place of wheelchair users. There are 2 areas of concern relating to the environment: A requirement has been made in each of the last 2 inspection reports to ensure that a hot water supply is available in room 10. On this inspection this was seen to have been done, however there was no hot water supply in another bedroom inspected. Additionally a resident in room 11 made a complaint during the inspection that there was no hot water supply to his room and that he had to wash in cold water. This is on the first floor. There are ongoing problems with the heating system and modifications required to the heating system boiler. This work is scheduled to take place soon. A requirement is made to ensure that adequate supplies of hot water are available at all times. CSCI must be notified when the changes are made and hot water available to all. Another resident complained that one of the bathrooms with toilet on the same floor had out of use for 2 months awaiting repairs. She also complained about the lack of cleanliness in the toilet areas and had made a request for a toilet to be available separately for males and females. She said that this has been raised and discussed at residents meetings. The situation at this time is that there are 3 bathrooms, one assisted on the ground floor and 2 unassisted on the first floor, one of which is the one referred to above. The greatest difficulty is the unavailability of the toilet in the bathroom awaiting repairs. There are 18 people in bedrooms on the first floor, 4 of whom are females. There are presently only 3 toilets available and Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 21 the condition of them not acceptable to some residents. There are no en-suite facilities available in this home. This matter was discussed with the Manager who will take steps to resolve the matter with residents as soon as possible. A requirement is made for the providers to ensure that adequate toilet facilities must be made available to residents. CSCI must be notified when work has been carried out and the bathroom available again to residents. The planned building and refurbishment work will increase the facilities available but meanwhile adequate toilet facilities and constant hot water must be available to residents as required in Regulations. A resident complained about the laminate flooring in his bedroom. Several rooms have been fitted with this flooring but the resident did not like it and preferred the room to be carpeted. This was discussed with the Manager who will arrange for this to be done. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. There are competent well trained staff providing effective support to residents. Staff recruitment procedures have improved and protect residents. EVIDENCE: All staff have job descriptions clearly defining roles. Key workers are allocated to all residents. The number of staffing hours remain around 520 per week. There are generally 3 care staff on duty throughout the day plus Manager and plus the Activities Organiser. There have generally been 3 waking night staff, although it was noticed from the staffing rota that this often reduces to 2. The reason given was unavailability of staff. The night staffing levels must be kept under review in the light of the changing needs of residents. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 23 NVQ training is offered to all staff. All staff on duty during the day have completed NVQ2 or above. Two night care staff have not been involved in NVQ study but will be offered courses. A weak area in the home has been in the area of staff recruitment procedures. Requirements have been made in previous reports. A sample of staff files were seen on this visit and there was some improvement, although in one instance only 1 reference had been obtained prior to employment. Records showed that POVA checks or CRB checks had been obtained for all new employees, prior to employment. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is well run and managed in the interests of residents. Some action is required to ensure fire safety. EVIDENCE: The previous Registered Manager left the home last year for another appointment in the group. Since that time the former Deputy has been Acting Manager until her approval by the Commission in June this year as the Registered Manager. She is presently involved in study for the Registered Managers Award which she hopes to complete in March 2007. There is an open management style in the home and good engagement between staff and residents. There is a quality assurance system to inform managers about service delivery and customer satisfaction. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 25 Policies and procedures are in place to inform practice. Record keeping is to a high professional standard. Staff training has been provided meeting statutory requirements and professional development. Fire records showed that routine checks of equipment had been carried out. It was disturbing to experience that when the fire alarm sounded in the home during the morning of the inspection (alert from sensor in smoking area) all staff proceeded to move from the first floor to the front entrance hall, but none of the residents made moves to leave the building. – Fire drills must be carried out on a regular basis and include residents. Under new fire regulations individual evacuation plans should be provided for each resident. It was noted that fire the door on the entrance to the dining room did not close onto the rebate. This must be rectified. The financial viability of the home is reflected in the ongoing re-investment already made and in the plans for the future. The development plan also includes Training & Development, Quality Standards, Care Practice and Marketing & Promotion – also important factors in providing a high quality service. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 1 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 2 3 Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Timescale for action 18/11/06 2 YA27 3 4 5 YA42 YA42 YA27 Establish written protocol with resident/relative re. Supply & monitoring of medication and complete risk assessment. 23(2)(j) Adequate toileting facilities must be provided. Notify CSCI when bathroom on first floor is operational. 23(4)(a)(b) Fire drills must be carried out on a regular basis and residents involved in the process. Ensure all fire doors close onto 23(4)(a(b) rebates in the interests of fire safety. 23(2)(j) Adequate supplies of hot water must be available at all times. Notify CSCI when boiler problems are resolved. 18/11/06 30/11/06 18/11/06 18/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations Wound dressings must remain the responsibility of the DS0000008258.V320307.R01.S.doc Version 5.2 Page 28 Weston House District Nursing service. Care staff must not be involved in wound dressing changes. 2 YA26 Discuss with resident alternative to laminate flooring in bedroom identified. Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Weston House DS0000008258.V320307.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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