Inspection on 22/08/06 for Westwood

This inspection was carried out on 22nd August 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

Westwood 16/11/07

Westwood 15/11/05

Westwood 19/07/05

Westwood 17/05/05

Westwood 02/02/05

Westwood 14/10/04

Westwood 03/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Westwood 284 Bath Road Worcester Worcestershire WR5 3ET Lead Inspector N Andrews Unannounced Inspection 09:30 22 and 23 August 2006 nd rd 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 Westwood DS0000018697.V308793.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. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Address 284 Bath Road Worcester Worcestershire WR5 3ET 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) 01905 353866 Mr Anthony Harold Downer Mrs Zinnat Esmail Downer Mr Anthony Harold Downer Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is primarily for people over the age of 65 who have care needs arising from old age but not from other disabilities or mental disorders. The Home may accommodate two named people who have needs outside of this category and were resident before 13 December 2005. 15 November 2005 Date of last inspection Brief Description of the Service: Westwood is a bungalow that has been adapted and extended for its present purpose as a residential care home. The home is situated in a residential area on a main road out of Worcester City and is convenient for local amenities and transport. There is a car parking area at the front of the premises and a large garden at the rear. The service users are accommodated on one level in eight single bedrooms and two double bedrooms. Six of the single bedrooms and one of the double bedrooms have an en-suite facility. There are communal toilets and bathrooms, a dining room and three lounge areas. In addition, there is a spacious, furnished veranda. The premises are well maintained and furnished in a comfortable and homely manner. The registered providers and their two children live on the premises in their own private accommodation. The home is registered to provide personal care for a maximum of twelve people of either sex over the age of sixty-five years who have mild to moderate needs associated with old age. At the time of the inspection there were ten people in residence and two vacancies. The fees range from £1400.00 to £1580.00 per month. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over two days. The inspection included time spent with the registered providers assessing the progress made by the home in implementing the requirements and recommendations arising from the previous inspection. Various records that the home is required to maintain were inspected and individual discussions were held with two service users, the relatives of two service users and two members of staff. A brief tour of the premises was also carried out. As part of the inspection ‘Comment Cards’ were issued to a small number of relatives/visitors and to visiting professionals. A total of eight Comment Cards were completed and returned. The majority of the responses to the questions that were asked were positive. What the service does well: The service users lived in a clean, comfortable and homely environment. Secure storage was provided for medication and medication records were accurate and up to date. The service users felt that they were treated with respect and that their right to privacy was upheld. The service users were able to maintain contact with their relatives and friends and were able to exercise choice. The home provided a balanced and wholesome diet. The service users enjoyed a positive relationship with the staff and felt confident about making a complaint if necessary. The home provided satisfactory laundry facilities. The home was being managed by an experienced and appropriately qualified registered manager. The relatives of four service users expressed additional positive comments in the ‘Comment Cards’. One relative stated that they chose the home ‘because it seemed pleasant and friendly, so far we haven’t been disappointed’. Another relative stated, ‘The cleanliness, care and medical attention is excellent’. Another relative felt that the home should be used as a Government guide to the way all homes should be run and stated, ‘My mother has come on wonderful since coming here. I cannot praise it enough’. Another relative stated ‘The standard of care at Westwood is very good’. The two ‘Comment Cards’ that were completed by visiting professionals also contained additional positive comments. One visiting professional stated, ‘I am very satisfied with the care given and the general atmosphere within the home’. The other respondent described the overall care provided as ‘excellent’. It should also be noted that in April 2006 the CSCI received a letter from the relatives of a former service user. The relatives wished to express their ‘total satisfaction’ with the home and their ‘debt of gratitude’ to the registered providers and staff for the ‘care and dignity’ they afforded their father whilst he was resident in the home. The registered providers were given the opportunity to express their view about what the home does well. They stated that they provided high quality Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 6 care in a homely environment. They felt that the service provided by the home helped to take pressure off the service users’ relatives with whom they had developed a relationship of trust. They stated that because there was ‘no shouting between the staff’ the home provided a peaceful environment. The registered providers stated that they were ‘good at developing the staff to the standard that we expect’. What has improved since the last inspection? What they could do better: The statement of purpose and service users’ guide must be amended in order to enable prospective service users to make a fully informed choice about the home. The form used for assessing prospective service users must be improved in order to ensure that all of the service users’ needs are fully assessed prior to admission. The care plans must be completed accurately and reviewed in full each month in order to ensure that all of the service users’ needs are appropriately met. The range of social and leisure activities should be increased. The policies and procedures in regard to complaints and the protection of vulnerable adults from abuse must be amended and awareness of them by staff and visitors increased. Various improvements to the physical environment were required for the benefit and safety of the service users. These included the provision of a lockable storage space in each bedroom, liquid soap and paper towel dispensers in the laundry, thermostatically controlled mixer valves to all hot water outlets used by service users, a fire door in the main corridor and the refurbishment of the bathroom. The policy and procedure on infection control needed to be revised. Staff training and training records needed to be improved and the staff recruitment procedures must become more robust in order to ensure the safety of the service users. The quality assurance system, that the registered providers stated had been in place since 2003, needed to be developed. Individual staff supervision must become more frequent and risk assessments must be carried out and recorded. The registered providers were given the opportunity to express their view about what they could do better. They said that they needed to allocate more time to improving the statement of purpose and service users’ guide and that the bathroom needed to be refurbished. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 7 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. Westwood DS0000018697.V308793.R01.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 Westwood DS0000018697.V308793.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. Further work was needed to ensure that prospective service users are provided with clear and sufficient information to enable them to make a fully informed choice about the home. The form that is used to assess the care needs of prospective service users must be amended so that a full and accurate care plan can be prepared and to ensure that all of their care needs are met. EVIDENCE: Three requirements were made in regard to Standard 1 as a result of the previous inspection. The first and third requirements were made in respect of improvements to the home’s statement of purpose and service users’ guide. The registered manager stated that he had begun the process of amending both documents and had nearly completed the exercise. However, the requirements had not been fully implemented and still stand. The requirements were discussed with the registered manager who was reminded of the importance of ensuring that both documents contained all of the relevant information. It was pleasing to note that the third requirement regarding an application to the CSCI for a variation in conditions of registration had been implemented. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 10 The registered manager confirmed that the home was now operating within the conditions of registration. A requirement was made in regard to Standard 2 as a result of the previous inspection. The requirement concerned improvements to the home’s statement of terms and conditions of residence (contract). A copy of the contract was made available for inspection. The contract, which is headed ‘Agreement of Care’, included relevant information. However, the contract must also include a specific reference to the rooms to be occupied as indicated in Standard 2.2. In addition, the incorrect reference in paragraph 5 to the ‘Care Standards Commission’ and the out of date reference in paragraph 16 to ‘County Inspectorate’ should be changed to the Commission’s correct title i.e. Commission for Social Care Inspection. An amended copy of the contract must be given to each service user and/or their representative to sign and a signed and dated copy kept on the service users’ individual files. The requirement had not been fully implemented and still stands. A copy of the home’s assessment form was made available for inspection. The assessment form was headed ‘Checklist for Assessment and Care Planning’ and contained a reference to a number of relevant aspects of care. The assessment form would help the registered persons to obtain specific information about the care needs of prospective service users. However, the assessment form did not include a reference to all of the aspects of care referred to in Standard 3.3. The assessment form must also include a reference to the following issues, • Communication, • Social interests, hobbies, religious and cultural needs, • Personal safety and risk, • Carer and family involvement and other social contacts/relationships. In addition, the assessment form should also include the name and address of the home, the name of the prospective service user and the date on which the assessment was carried out. The format of the assessment form should also be revised in order to provide sufficient space to record all of the relevant information regarding the service users’ needs. The registered providers stated that two of the service users who were privately funded had not been assessed and had not undergone a community care assessment. The assessment of another service user had not been completed. Westwood DS0000018697.V308793.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users are treated with respect by the staff and their right to privacy was upheld. The service users’ health care needs were being met. However, the lack of detailed recording in the service users’ care plans meant that some aspects of their care were being overlooked. As a consequence, the service users were being exposed to potential risks. EVIDENCE: It was confirmed that all of the service users had a care plan and there was evidence to show that the care plans were being reviewed each month. However, the care plans did not include a reference to all of the aspects of care referred to in Standard 3.3 and the monthly reviews of the care plan did not include a review of all aspects of care. The format of the care plans needed to be amended in order to show clearly the identified needs of the service users. Most importantly, the care plans must also include the specific details of the action that has be taken by the care staff in order to ensure that all of the service users’ needs are met. Evidence must be provided to show that all aspects of the service users’ care are being reviewed at least once a month including those aspects of care where there has been no significant change. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 12 The staff had responded appropriately to one service user who had developed a pressure sore that the registered providers stated had been acquired during her stay in hospital. One service user received visits from the community psychiatric nurse. The home had requested the help of the continence adviser. The continence adviser’s visit was awaited. A chiropodist visited every 6 to 8 weeks and provided a fee-paying service to most of the service users. An NHS chiropodist also visited infrequently to attend to the needs of one service user. The last visit was on 22 August 2005. The last request by the home for a further visit was made in May 2006. The home was still awaiting a response. The registered providers were urged to take further action to ensure that the service user received appropriate treatment as soon as possible. The registered providers stated that the service users received dental and ophthalmic treatment as and when necessary. It was also stated that hearing tests were arranged through the GP when needed. Two requirements were made in regard to Standard 8 as a result of the previous inspection. The first requirement concerned the assessment of service users who were at risk of developing pressure sores. It was confirmed that all of the service users had been assessed using a Waterlow Chart. The requirement had been implemented. The second requirement was made in connection with nutritional assessments. The registered providers confirmed that the service users were weighed regularly and that one service user was given a nutritional supplement as part of her diet. However, no specific recorded nutritional assessment had been carried out. The requirement had not been implemented and still stands. The registered providers were provided with relevant information on this issue following the inspection. It was noted that there were two service users who were at risk of choking. The registered providers confirmed that the service users’ food was mashed in order to assist swallowing and that a member of staff was always present at meal times to supervise the service users. It was also stated that the staff had undertaken first aid training. However, risk assessments had not been carried out. It was also noted that the majority of the service users were physically frail and in need of walking aids. Some of the service users had also suffered falls. However, risk assessments had not been carried out. A Notice of Immediate Requirement in regard to both of these matters was issued at the conclusion of the inspection. Medication is kept in a lockable cupboard. The medication records (MAR Charts) were checked and found to be clear, accurate and up to date. One of the registered providers and two other members of staff were involved in the administration of medication. It was confirmed that the registered provider had undertaken accredited training in the administration of medication. However, two other members of staff had only undertaken training in the Boots monitored dosage system (MDS) and not the full accredited training. All the staff involved in the administration of medication must undertake the full, accredited training. Accredited training courses in medication administration are provided at Worcester College, Solihull College and in the form of distance learning at Wolverhampton. Four requirements and two recommendations Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 13 were made in regard to Standard 9 as a result of the previous inspection. The first requirement was in regard to the development by the home of a procedure for homely medicines. It was confirmed that a policy and procedure had been developed. The policy and procedure was made available for inspection. It had been checked by the Boots’ pharmacist on 21 June 2006 and was regarded as a ‘well written document’. The requirement had been implemented. The second requirement concerned the discontinuation of eye drops a month after the container had been opened. It was confirmed that a date 28 days after the opening of the medication was written on the box containing the eye drops. The requirement had been implemented. The third requirement was that medication for external use must be physically separated and stored away from internal medication. It was noted that the two types of medication were now kept in two individual plastic lidded containers. The requirement had been implemented. The fourth requirement concerned the review of the medication policy and the inclusion of a procedure to follow in the event of an error. The requirement had not been implemented and still stands. The registered providers were advised to seek the assistance of their local Boots pharmacist in the implementation of this requirement, if necessary. It was confirmed that the home enjoyed a positive relationship with the local pharmacist. The reference to ‘Bethany Lodge’ in the medication policy was not relevant and should be deleted. The first recommendation was that hand written MAR charts should be checked and signed by two members of staff. The recommendation had been implemented. The second recommendation regarding the provision of a Controlled Drug cabinet had not been implemented. The registered providers confirmed that none of the current service users were in receipt of a Controlled Drug and that a Controlled Drug cabinet could be obtained quickly if the current situation changed. Nevertheless, the recommendation still stands. The service users with whom discussions were held confirmed that they were treated with respect and that their dignity was upheld. They also confirmed that they were treated with kindness by the staff. One service user said that there was ‘no over-familiarity’. The same service user confirmed that the staff always knocked the door before entering her bedroom. Speaking of the staff, a relative of one service user said ‘I think they’re angels’. The staff with whom discussions were held indicated that they understood the importance of maintaining the service users’ privacy and that they upheld their privacy and dignity in day-to-day practice. The staff confirmed that they always knocked the service users’ doors before entering their bedrooms. The home had a mobile handset to enable the service users to make and receive telephone calls in private. It was confirmed that the service users wore their own clothes at all times. One service user said that the staff called her by a different name because they found it difficult to pronounce her proper name. The service user confirmed that she was quite happy with this arrangement. The registered Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 14 provider stated that service users in need of medical treatment were always seen in private. Fixed screening was provided in both of the double bedrooms. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 15 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 and 15 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users expressed their satisfaction with the lifestyle experienced in the home, but they would benefit from a wider range of in-house and community activities. The service users were able to maintain contact with their relatives and friends and were able to exercise choice and control over their lives. The service users received a wholesome and balanced diet. EVIDENCE: The service users with whom discussions were held stated that they were happy with the daily routine. One service user said that she found the routine a little restrictive at first but that she had now adapted to it. It was stated that meals were only served in the service users’ bedrooms ‘if a resident was ill’. The registered provider stated that food was not served in the service users’ bedrooms for health and safety reasons. The registered provider also stated that the mid-morning and mid-afternoon drinks were served at the dining room table in order to encourage the service users’ mobility and to help ensure their safety and avoid accidents. The service users said that they were free to get up and go to bed when they wished. The service users said that they were happy with the range of social and leisure activities provided. These included a music and movement session every two weeks and two visiting musicians on alternate weeks, Scrabble and Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 16 other board games, large print cards, music and television. It was noted that a music and movement session was taking place during the inspection. An Anglican priest visits the home every month to hold a Communion service. The registered provider stated that the home did not have the staff or the transport facilities to take the service users out. These factors would limit the service users’ links with the community. A recommendation had been made as a result of the previous inspection that efforts are made to identify and expand the range of in-house activities that interest the service users. There was no evidence to show that the range of in-house activities had increased since the previous inspection. Whilst service users indicated that they were satisfied, it is the inspector’s view that some would benefit from a wider range of in-house and community activities. Therefore, the recommendation still stands. In addition, it is recommended that a record be maintained of all the activities that are held. The registered provider stated that visitors were welcome at any time except mealtimes. Both the service users and the relatives with whom discussions were held confirmed that visitors to the home were always made welcome. It was also confirmed that the service users were able to see their visitors in private and that the service users’ wishes about whom they saw or did not see would be respected. The service users’ guide should include information about the home’s policy on maintaining relatives and friends’ involvement with the service users. It was stated that members of the Worcester Youth Theatre had visited the home in the past and that service users had attended musical evenings at the local school. However, no volunteers were involved in visiting the home at the present time. The registered provider stated that the home did not handle any money on behalf of any of the service users. It was also confirmed that the home kept written information about the local advocacy service to give to the service users and/or their relatives if necessary. The service users’ guide should also include details of the advocacy service. It was confirmed that prospective service users were entitled to bring personal possessions with them when they were admitted to the home. The inspection of the service users’ bedrooms confirmed that this practice had been adopted. The registered provider stated that the service users were involved in reading and signing their care plans. The service users’ guide should include a statement that the service users or their representatives acting on their behalf have the right of access to all the personal records held about them by the home in accordance with the Data Protection Act 1998. The record of the food was made available for inspection. The record showed that a wholesome diet was provided. Breakfast was served at 8:00 am, lunch at 12:30 pm, tea at 4:45 pm and supper between 7:15 and 8:00 pm. The registered provider stated that the main cooked meal of the day was served at lunchtime, fish was served twice a week and there was always a roast on Sundays. Two service users had their food mashed or cut into small pieces in Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 17 order to enable them to eat it more easily. Three service users were diabetic. The home catered satisfactorily with their dietary needs. The service users with whom discussions were held commented positively about the food. One service user said that since her admission to the home her weight had increased. She said, ‘The food is on a par with the best’. It was confirmed that drinks and snacks were available throughout the day. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 18 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 and 18 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users had a good rapport with the staff and felt confident about making complaints. The home had a complaints procedure, a policy and procedure for the protection of vulnerable adults from abuse and a ‘whistle blowing’ procedure. However, all three policies and procedures must be amended and awareness of them by the staff, service users and their relatives increased in order to ensure the safety and protection of the service users. EVIDENCE: The registered provider stated that the home had not had any major complaints since the previous inspection. It was stated that complaints of a minor nature e.g. the meals were too hot and the room was too draughty etc, had been dealt with and resolved quickly. The home had a satisfactory complaints procedure. However, it was noted that the complaints procedure included an out of date reference to the National Care Standards Commission. This reference should be changed to the Commission for Social Care Inspection (CSCI). The home had a book in which any complaints made against the home could be recorded. The complaints book contained one entry dated 1 October 2004. It was pleasing to note that the service users and the relatives of the service users with whom discussions were held stated that they felt confident about making a complaint and that any complaint made would be dealt with quickly and appropriately. A recommendation was made as a result of the previous inspection that action should be taken to ensure that the service users and their relatives are made aware of the complaints procedure. The registered provider stated that the service users’ relatives had been informed verbally about the home’s complaints procedure. One service user and the Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 19 relatives of another service user also said that they were aware of the complaints procedure. However, one of the questionnaires that were returned from the service users’ relatives indicated that the respondent was unaware of the complaints procedure. In addition, two members of staff also said that they were not aware of the complaints procedure. Details of the complaints procedure must be included in the service users’ guide. Therefore, in order to ensure that the service users and their relatives are made fully aware of the complaints procedure it is recommended that a copy of the complaints procedure and/or a copy of the service users’ guide is issued to all of the service users and/or their relatives. It is also recommended that the contents of the service users’ guide including the complaints procedure is discussed with all of the staff and that a record is maintained to show that both of these recommendations have been implemented. The home’s response to Standard 17 was not assessed during this inspection. However, during the discussions with the service users one of the service users stated that she had not had the opportunity to vote. The registered provider stated that she would look into this matter and, if necessary, take the appropriate action to ensure that all of the service users were enabled to vote using the postal voting system. The registered providers confirmed that no alleged or suspected incidents of abuse had been reported to them or otherwise come to their attention since the previous inspection. It was also confirmed that no circumstances had arisen in which any member of staff who may be unsuitable to work with vulnerable adults had had to be referred for inclusion on the Protection of Vulnerable Adults (POVA) register. The home had a policy and procedure on the protection of vulnerable adults from abuse. However, the policy and procedure must be amended in order to include, • The name and telephone number of the Adult Protection Coordinator, • A statement confirming that all allegations or suspected incidents of abuse must be reported immediately to the Adult Protection Coordinator, • Details of the action to be taken in the event of an allegation of abuse being made against, or a suspected incident of abuse involving a member of staff. In addition, both the home’s policy and procedure on the protection of vulnerable adults from abuse and the home’s policy on ‘whistle blowing’ contained an out of date reference to the National Care Standards Commission. These references must be changed to the CSCI. The registered providers are referred to the Department of Health publication ‘No Secrets’ for further guidance on this matter. A recommendation was made as a result of the previous inspection that the staff, service users and visitors are informed that the staff are not permitted to receive gifts or bequests or assist service users to make their wills. The registered provider stated that the service users’ relatives had been informed verbally. However, there was no written evidence available to show that the Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 20 staff, service users or visitors/relatives had been informed. A policy and procedure that includes all of the issues referred to in Standard 18.6 should be developed and a written record maintained to show that a copy has been provided to all of the staff, service users and their visitors/relatives. This could be done by including details of the policy and procedure in the service users’ guide. Details of this policy and procedure may also be included in staff contracts and/or a staff handbook. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 21 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 and 26 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users lived in clean, comfortable and homely surroundings. However, amendments needed to be made to the home’s written documentation in order to underpin good practice and ensure the service users’ safety. EVIDENCE: The location and layout of the home was suitable for its stated purpose, accessible and maintained in a comfortable and homely manner. The presence of the registered providers’ two children and the provision of pictures, plants, an aquarium and two cats helped to enhance the provision of a homely atmosphere. The service users were accommodated on one level in eight single bedrooms and two double bedrooms. The bedrooms were clean, well maintained and personalised. There was ramped access on both sides of the property to the large, rear garden. It was evident that repairs and refurbishment were being carried out. For example, it was confirmed that the dining room chairs and a number of armchairs had been re-upholstered. However, the home did not have a written programme of routine maintenance and renewal of the fabric and decoration of the premises. The registered Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 22 provider stated that ‘what gets done depends on the income’. Whilst this comment is accepted, a written programme of maintenance and renewal would help to ensure that all aspects of the environment were kept under regular review. The last visit to the home by the Fire Safety Officer took place on 13 February 2004. The subsequent letter dated 16 February 2004 stated that consideration should be given to reinstating the FD 3S fire-resisting door in the corridor. Serious consideration should be given to the implementation of the recommendation due to the potential risks to the service users in the event of a fire occurring within the home. The registered manager was also advised that, if any of the service users wished to have their bedroom door wedged open, a release mechanism that is linked to the home’s fire detection system that will close the door automatically in the event of the alarm being sounded must be installed. The registered provider did not have a record of the last visit by the Environmental Health Officer. However, the registered provider stated that the most recent visit occurred during 2005. It was also confirmed that all of the recommendations arising from the Environmental Health Officer’s visit had been implemented except for one outstanding issue i.e. that a part of the kitchen should be repainted. A requirement was made as a result of the previous inspection that the lock on one en suite door must be repaired and the extraneous articles removed from the service users’ shower and bathrooms. It was noted that the lock had been removed altogether from the door of the en suite facility. The service user confirmed that she was in agreement with the action that had been taken. No extraneous items were being stored in the en suite facilities. The requirement was regarded as having been implemented. However, it was also noted that one of the bathrooms was in need of refurbishment. The home’s response to Standard 24 was not fully assessed. However, it was noted that not all of the bedrooms contained a lockable storage space for medication, money and other valuables. This facility must be provided in order to enhance the service users’ safety and independence. The registered manager is advised to carry out an audit of all the bedrooms in order to ensure that they contain all of the items of furniture listed in Standard 24. The premises were clean and tidy and there were no unpleasant odours. One of the service users with whom a discussion was held stated ‘The bed linen is changed regularly and the laundering of the clothing is very good’. The home had a satisfactory laundry that was situated in a small, separate building at the side of the premises. Soiled articles could be taken to the laundry without the staff having to pass through areas where food was stored, prepared, cooked or eaten. The laundry contained hand-washing facilities. The laundry floor and wall finishes were satisfactory. The home’s infection control policy and procedure was made available for inspection. The policy and procedure was a one-page document and did not include a reference to all of the relevant issues normally associated with such an important document. The infection control policy and procedure must be reviewed and upgraded in accordance with the ‘Guidelines for Infection Control in Care Homes’ dated 2003 issued by the Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 23 Herefordshire and Worcestershire Local Health Protection Unit. The infection control policy must include the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing and hand washing. A requirement was made as a result of the previous inspection that liquid soap and disposable towels must be readily available in the laundry. The requirement had not been implemented and still stands. The communal bathroom and toilet facilities contained paper towels or liquid soap but not both. The requirement to provide liquid soap and paper towel dispensers in the laundry has, therefore, been extended to include all of the communal washing facilities. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 24 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 and 30 The quality outcome in this area was poor. This judgement has been made using available evidence including a visit to this service. The service users stated that the staff were kind, helpful and supportive. However, the arrangements for recruiting, training and deploying staff were not good enough to ensure that service users are in safe hands at all times. EVIDENCE: A copy of the staff rota was made available for inspection. In addition to the registered providers, five other members of staff were employed at the home as follows, • one night care assistant was employed for two nights per week i.e. a total of 22 hours per week, • one care assistant was employed for 15 hours per week (day time) and three nights (33 hours) per week i.e. a total of 48 hours per week, • two care assistants were employed for a total of 75 hours per week (day time), and • one member of staff was employed for 40 hours per week (day time) to carry out both caring and cleaning duties. One member of staff was on waking duty at night. The registered providers were involved in the day time staffing and, in addition, usually carried out the sleeping-in duties at night. The total number of care assistant hours (daytime) that was provided by staff excluding the registered providers was approximately 110 hours per week. The level of staff cover provided limited the opportunities for service users e.g. to be involved in community based activities. The staff rota showed that there were days when only two members of staff were on duty throughout the main part of the day i.e. from 8:00 am to Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 25 6:00 pm. The staff rota also showed that one member of staff had had only three days off during a period of three weeks. Consideration should be given to providing additional staff on duty at peak times of activity during the day. The staff rota also showed that there were two occasions within a three week period when one member of staff worked from 6:00 pm to 9:00 pm and then continued working throughout the night from 9:00 pm to 8:00 am the following day i.e. 14 hours. The registered providers subsequently stated that the particular member of staff had had a break between shifts. They also stated that this was a ‘one off situation’ to cover a holiday period. However, this practice should be discontinued. The staffing arrangements must ensure that staff remain alert at all times particularly during the night in order to attend to the needs of the service users and to respond appropriately in the event of an emergency. It was pleasing to note that the home employed three Polish workers who were able to communicate with two service users in their first language. The registered manager has completed the NVQ level 4 training. The other registered provider has completed an NEB course in Supervisory Management at the college in Bromsgrove. However, apart from the registered manager, none of the staff have completed the NVQ level 2 training. In order to meet the standard of NVQ training that is required arrangements must be made to enrol staff on accredited NVQ level 2 training courses at the start of the new academic term commencing shortly. The files of several members of staff were inspected. It was noted that in the case of two members of staff only one written reference had been obtained. However, the registered providers subsequently made a second reference available in respect of one of the staff. It was also noted that one member of staff had a CRB disclosure that related to her previous employment and not to her current employment at the home. The registered manager was informed that CRB checks are not ‘portable’ i.e. not transferable, and that a new CRB disclosure application must be made in respect of all prospective staff prior to their appointment at the home. A Notice of Immediate Requirement was issued in regard to these issues at the conclusion of the inspection. The staff files must also contain proof of identity i.e. a photograph and a copy of the member of staff’s birth certificate and current passport (if any). It was also noted that four members of staff had not been issued with a copy of a statement of their terms and conditions of employment (contract) or with a copy of the code of conduct and practice set by the General Social Care Council. The home provided induction training through CQM Training and Consultancy Ltd. The documentation on the training that was called ‘Working in Care Induction Standards Framework’ stated that it was a TOPSS Accredited Course. The registered provider stated that all of the recently appointed staff had undergone the formal induction training and there was evidence on the staff files to support this comment. The staff files also contained evidence to show Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 26 that staff had undertaken training within the previous twelve months in a number of areas including abuse awareness (28/09/05), basic first aid (12/10/05) and continence management (13/06/06). However, the individual training and development assessments and profiles did not contain evidence to show that the effectiveness of the training had been discussed or assessed and that this was linked to future plans to meet the staff training needs. Although the registered manager had developed a staff-training matrix, it was stated that the information in the matrix was not up to date. The matrix did not include the dates of the training. Therefore, it was not possible to fully assess the level of staff training. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 27 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, 36 and 38 The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is appropriately qualified and experienced for the role but the safety and well being of the service users would be better assured if all care management practices were fully and consistently implemented. EVIDENCE: The registered manager had appropriate experience and skills to manage the home. It was confirmed that he had obtained the NVQ level 4 and the Registered Managers’ Award on 14 June 2004. The registered manager also stated that he had undertaken other relevant core training in 2005 on first aid, abuse awareness, moving and handling and fire safety. The registered manager confirmed that the fire safety training that he had undertaken was at a level appropriate for a registered manager i.e. the Fire Safety Training for Managers training. Similarly, the training that is undertaken on the protection of vulnerable adults from abuse must be at a more advanced level than the abuse awareness training and more appropriate for registered managers. First Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 28 Aid at Work training carried on over several days is also more suitable for staff with supervisory or management responsibility than the basic first aid training. It was pleasing to note that the staff with whom discussions were held stated that the registered providers were approachable and supportive. The home’s response to Standard 32 was not fully assessed during this inspection. However, the registered provider stated that formal staff meetings were not held and that discussions with staff usually occurred informally during break periods. It is good management practice to hold regular staff meetings in order to maintain an open, positive and inclusive atmosphere. A full staff meeting should be held at least twice a year, preferably once a quarter, with a written agenda to which members of staff may contribute. A record should be maintained of the minutes of each meeting. Staff meetings could be used to discuss a range of important issues including the home’s policies and procedures, care plans and care practice issues, risk assessments, the home’s complaints procedure, the service users’ social and leisure activities and the National Minimum Standards. The registered manager confirmed that a survey had been carried out in December 2003 and November 2005 using a document that he had developed during his NVQ level 4 training. Both surveys had been directed towards obtaining the views of the service users’ relatives. The surveys should be extended to incorporate the views of other stakeholders e.g. GP’s, district nurse and other visiting professionals. The quality assurance system, of which the user satisfaction surveys may form a part, needed to be developed. The home did not have an annual development plan. The registered manager was advised to set aside dedicated time each week in order to address all of the requirements and recommendations arising from inspection reports. The registered providers stated that the service users and/or their relatives were expected to retain responsibility for their own money and personal possessions. It was confirmed that the registered providers did not handle any of the service users’ money or act as an agent or appointee on behalf of any of the service users and, therefore, no personal allowances or any financial records in respect of the service users were maintained by the home. It was also confirmed that the home did not hold any personal valuables in safekeeping on behalf of any of the service users. The registered manager stated that prospective service users were discouraged from bringing any expensive jewellery with them when they were admitted. There was evidence to shown that individual staff supervision was being carried out. However, supervision meetings were not being held at the required frequency and did not cover all of the issues referred to in Standard 36.3. A recommendation was made as a result of the previous inspection that a full range of policies and procedures should be available to inform and guide staff Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 29 in their duties. The registered manager stated that all of the home’s policies and procedures were kept in a manual of procedures. It was noted that the staff had not confirmed in writing that they had read and understood all of the policies and procedures. Some of the policies and procedures that were in need of amendment were identified during this inspection and are referred to in this report. There may be other policies and procedures that are referred to in the previous inspection report that still need to be developed e.g. aggression by service users towards staff, the control of substances hazardous to health (COSHH) etc. The registered manager should continue to review all of the home’s documentation in order to ensure that all of the policies and procedures required by the home in accordance with the National Minimum Standards and Care Homes Regulations are provided, reviewed and available for inspection. Some of the core training had not been completed by all of the staff. In particular, it was noted that one member of staff had not undertaken first aid or abuse awareness training, the registered manager and one other member of staff had not undertaken continence management or food hygiene training, three members of staff had not undertaken infection control training and none of the staff had undertaken health and safety training. The registered manager subsequently stated that he had a qualification in food hygiene and that he would undergo a course of training in continence management in due course. One member of staff who had been in post for approximately six months stated that she had not undertaken any moving and handling training. All of the above training must be completed by all of the staff. It was noted that, because the ground at the rear of the home descends in height, three bedrooms and a lounge at the rear of the premises were above ground floor level. Opening restrictors had not been fitted to the windows and risk assessments had not been carried out. Risk assessments must be carried out in respect of all of the safe working practice topics listed in Standards 38.2 or 38.3. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. The registered manager stated that he intended to ensure that thermostatically controlled mixer valves were fitted to all hot water outlets used by service users. The accident book was made available for inspection. It was noted that a service user had sustained a fall on 23 April 2006 that had necessitated admission to hospital. The accident had not been reported to the CSCI. The registered providers subsequently stated that the accident had not been reported to the CSCI because it had occurred on a Sunday when the CSCI office was closed and the service user had fully recovered by the following day. It is accepted that registered persons have to use their professional judgement when deciding what incidents or events to report to the CSCI. However, accidents of a potentially serious nature that result in the service users’ admission to hospital must always be notified to the CSCI in accordance with Regulation 37. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 30 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 1 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 1 Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 31 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 OP1 Regulation 4 Requirement Timescale for action 31/10/06 2 OP1 5 3 OP2 5 A Statement of Purpose that contains all the information listed in Schedule 1 of the Regulations must be available within the home. A copy must be provided to the Commission for Social Care Inspection before the timescale expires. (Previous timescale 01/02/06 not met). A Service Users’ Guide 31/10/06 containing all the elements listed in Standard 1.2 must be given to each service user and a copy sent to the Commission for Social Care Inspection before the timescale expires. (Previous timescale 01/02/06 not met). 31/10/06 The home’s statement of terms and conditions of residence (contract) must contain all the elements listed in Standard 2.2 and be amended in accordance with the guidance given in this report. A copy must be provided for every service user when they are admitted to the home and a signed and dated copy kept on each service user’s individual file. A blank copy must be sent to the Commission for Social DS0000018697.V308793.R01.S.doc Version 5.2 Westwood Page 32 4 OP3 14 5 OP7 15 6 OP8 14 7 OP8 13 8 OP8 13 9 OP9 13 10 OP9 13 Care Inspection before the timescale expires. (Previous timescale 01/02/06 not met). The home’s assessment form must be revised in accordance with Regulation 14 and the guidance given in this report and a copy of the form completed prior to the admission of any prospective service user. The service user plans must cover all aspects of care as set out in Standards 7.2 and 3.3, be signed by the service users and reviewed at least once a month. Nutritional assessments must be undertaken on all current service users and on all new admissions and, thereafter, on a periodic basis to ascertain if there are any needs that should be addressed through the care plans. (Previous timescale 01/02/06 not met). A risk assessment must be carried out and recorded in respect of two service users identified as being at risk of choking. A risk assessment must be carried out and recorded in respect of all service users at risk of falling. All staff involved in the administration of medication must undertake accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. The medication policy should be reviewed and include a procedure to follow in the event of a medication error. (Previous timescale 01/02/06 not met). DS0000018697.V308793.R01.S.doc 31/10/06 31/10/06 31/10/06 30/09/06 30/09/06 30/11/06 30/09/06 Westwood Version 5.2 Page 33 11 OP18 12,13 12 OP18 12,13 13 OP24 16 14 OP26 13,16 15 OP26 13,16 16 OP28 18 17 OP29 17,19 18 OP29 17,19 The home’s policy and procedure for the protection of vulnerable adults from abuse must be amended in accordance with the guidance given in this report. The home’s ‘whistle blowing’ policy must be amended in order to include an appropriate reference to the CSCI. All of the items of furniture specified in Standard 24.2 including a lockable storage space must be provided in rooms occupied by service users. The home’s policy and procedure on the control of infection must be reviewed and revised in accordance with the ‘Guidelines for Infection Control in Care Homes’ dated 2003 issued by the Local Health Protection Unit and Standard 26.5 as outlined in the guidance given in this report. Liquid soap and paper towel dispensers must be provided in the laundry and in close proximity to all of the handwashing facilities in the communal bathrooms and toilets. (Previous timescale 15/11/05 not met). Arrangements must be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent. Two relevant, written references must be obtained in respect of all prospective staff prior to their appointment and any gaps in employment records explored. An enhanced disclosure check from the Criminal Records Bureau must be applied for in respect of all existing staff for whom a CRB disclosure check has not already been obtained by the home. DS0000018697.V308793.R01.S.doc 31/10/06 30/09/06 31/12/06 30/11/06 31/10/06 31/07/07 24/08/06 24/08/06 Westwood Version 5.2 Page 34 19 OP29 17,19 20 OP29 7,9,19 21 OP29 18 22 OP33 24 23 OP36 18 24 OP38 18 25 OP38 13 26 OP38 12,13 27 OP38 37 An enhanced disclosure check from the Criminal Records Bureau must be obtained for all prospective staff before their appointments are confirmed. The staff files must contain proof of identity and other documentation in accordance with Regulation 19, and Schedule 2 as outlined in this report. All members of staff must be issued with a statement of terms and conditions of employment (contract) and a copy of the code of conduct and practice set by the GSCC. The quality assurance system must be further developed in accordance with the requirements of Regulation 24 and Standard 33. Care staff must receive formal supervision at least six times a year that includes all of the issues referred to in Standard 36.3. Training must be undertaken by all of the staff in all of the core areas in accordance with Regulation 18 and the guidance given in this report. Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. Thermostatically controlled mixer valves must be fitted to all hot water outlets used by service users. The CSCI must be notified without delay of any serious accident or any event in the home that adversely affects the wellbeing or safety of any service user in accordance with Regulation 37. DS0000018697.V308793.R01.S.doc 24/08/06 30/09/06 31/10/06 30/11/06 31/03/07 30/11/06 30/09/06 31/03/07 30/09/06 Westwood Version 5.2 Page 35 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 2 Refer to Standard OP8 OP9 Good Practice Recommendations Appropriate action should continue to be taken to ensure that the service user in receipt of the NHS chiropody service receives the required treatment. A Controlled Drug cabinet, that meets the Misuse of Drugs (Safe Custody) Regulations 1973, should be obtained in the event that a Controlled Drug has to be stored in the home. The range of social and leisure activities should be increased in accordance with the service users’ needs and interests and a record maintained of all the activities that take place. The service users’ guide should include information about the home’s policy of maintaining the relatives and friends’ involvement with the service users. The service users’ guide should include a statement that the service users or their representatives acting on their behalf have the right of access to all the personal records held about them by the home in accordance with the Data Protection Act 1998. The complaints procedure should be amended to include a correct reference to the CSCI. A record should be maintained to show that a copy of the home’s complaints procedure, e.g. as outlined in the service users’ guide, has been issued to all of the service users and/or their relatives and that the contents of the service users’ guide, including the complaints procedure, have also been discussed with all of the members of staff. A policy and procedure that includes details of all of the issues referred to in Standard 18.6 should be developed and written evidence should be maintained to show that a copy has been provided to all of the staff, service users and their visitors/relatives. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented. DS0000018697.V308793.R01.S.doc Version 5.2 Page 36 3 OP12 4 5 OP13 OP14 6 7 OP16 OP16 8 OP18 9 OP19 Westwood 10 11 12 13 14 15 OP19 OP19 OP19 OP27 OP27 OP30 16 17 18 19 OP30 OP32 OP33 OP37 The FD3S fire-resisting door in the main corridor should be reinstated in accordance with the recommendations of the Fire Safety Officer. The recommendation that was made by the Environmental Health Officer in 2005 for part of the kitchen to be repainted should be implemented. The bathroom should be refurbished. Consideration should be given to providing additional staff on duty at peak times of activity during the day. The practice of staff working long shifts i.e. from 6:00 pm to 8:00 am, should be discontinued. The individual training and development assessments and profiles should include evidence to show that the effectiveness of the training undertaken by staff has been discussed and assessed. The home’s staff training matrix should be kept up to date and include the dates of all the proposed staff training and the dates when the training has been completed. A staff meeting should be held at least twice a year with a written agenda and recorded minutes. An annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users should be introduced. A full range of policies and procedures should be available to inform and guide staff in their duties. When the staff have read and understood the home’s policies and procedures they should be asked to confirm the same in writing. Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Westwood DS0000018697.V308793.R01.S.doc Version 5.2 Page 38 - 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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