Inspection on 27/07/06 for Westwood

This inspection was carried out on 27th July 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 12/07/07

Westwood 13/10/05

Westwood 25/04/05

Westwood 08/10/04

Westwood 30/06/04

Westwood 23/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Westwood 9 Knoyle Road Brighton East Sussex BN1 6RB Lead Inspector Elizabeth Dudley Key Unannounced Inspection 27th July 2006 10:00 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 DS0000014260.V296955.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 DS0000014260.V296955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Address 9 Knoyle Road Brighton East Sussex BN1 6RB 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) 01273 553077 Mr Mohamed Saber Sadek Mrs Sadek Mr M S Sadek Mrs Somaya Sadek Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of service users accommodated must not exceed twentynine (29) The service users will be aged sixty-five (65) or over on admission Date of last inspection 13th October 2005 Brief Description of the Service: Westwood is a privately owned residential home, registered to provide personal care for 29 older people. The building consists of two semi-detached properties converted for its current use. Accommodation is presented across three levels, ground, first and second floors, accessed by a shaft lift. This includes seventeen single and three double bedrooms, seventeen of these 20 rooms having en-suite facilities. The home has communal facilities that include a lounge/dining room and an attractive garden that has access for wheelchairs. Situated in a residential area on the outskirts of Brighton, it is close to a main bus route and local parks. Although there are no car parking facilities at the home, all adjoining roads have unrestricted parking. Current fees charged range between £267.80 to £450 per week. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 27th July 2007 over a period of seven and a half hours. During the course of the inspection a tour of the home took place, thirteen residents, one visitor and six members of staff were spoken with and a further five relatives of residents spoken with by telephone. Prior to the inspection questionnaires were sent to residents and relatives of residents and the comments from these helped to inform the inspection. On the day of the inspection a tour of the home was undertaken and documentation, including care plans, medicine administration charts, personnel files, health and safety and catering records were examined. Many positive comments were received about the home with residents saying ‘It’s a good home, very comfortable and the staff are nice’, ‘The food is OK and there is always plenty of it’ and ‘We see the owner a lot, he is very pleasant and does everything to help us’. Comments from relatives included ‘The manager and staff seem to care about their elderly people, everyone is treated as an individual’, ‘There is a nice rapport within the home, they care about individuals, and care about each resident independently’ and ‘The staff are good and do their utmost to try to get my mother to join in. It is a good home and this is the second member of my family to have been in this home, they are like a big family’. One relative of a resident commented that ‘I have one concern that no one informed me when my mum had fallen but that is a one off’. Another stated ‘They keep me well informed about any concerns about my relative in the home’. Mr M Sadek, owner and manager, facilitated the inspection and thanks are extended to Mr Sadek, the residents, staff and relatives of residents for their help and courtesy during this inspection. What the service does well: Both residents and visitors to the home commented on the ‘homely atmosphere’ and the ‘family environment’ with relatives of residents speaking highly of the care given, the friendliness of the staff and the way that the home treats its residents as ‘individuals’. One relative said that this was the second member of her family to have lived at Westwood and that she was very satisfied with the care given and the atmosphere within the home. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 6 Westwood has an informal atmosphere and residents are treated as part of a family with a sense of community prevailing within the home. All residents stated that they have a choice over what they do and how they spend their days and although the food is of a homely nature and not always in keeping with the seasons, it is in line with the tastes of the present residents. Residents said that it was good, usually well cooked and that it was plentiful and that they could have snacks at any time of day or night and that ‘the girls will always make me a cup of tea’. The owner of the home spends time with residents and all of them spoke well of him and were pleased that he comes into their rooms to talk with them ‘If there is anything I am worried about I just speak to him and let him sort it’. Residents all stated that they related well to the staff and that the staff were happy to spend time with them and will listen to them. During the inspection it was noted that moving and handling training had not taken place and there was no moving and handling equipment within the home, a letter was received by the CSCI four days after the inspection to state that training had now taken place and new equipment, including a full body hoist had been purchased. The owner is commended on having acted so promptly. What has improved since the last inspection? The home has complied with the majority of the requirements made at the last inspection and these included redecoration of most internal and external parts of the home, new carpets and curtains and a new dishwasher being provided. The documentation within the home relating to personnel files and health and safety documentation and training has much improved and the home has come a long way to complying with legislation and ensuring the safety of residents and staff. Some activities have been commenced and residents said that they could choose whether to join in or not. One resident said that staff take the time to come and play chess with him in his room. The standard of cleanliness and tidiness within the home has improved and the rubbish from the garden has been removed thereby allowing residents a lovely garden in which to sit. Some residents spend a lot of time in the garden when weather permits. Although the report does not show the extent of the work that has taken place as there are still some standards to be met, the home has come a long way in the past twelve months to meeting the requirements made and the National Minimum Standards, and it is anticipated that in the near future that Westwood will fully meet the standards and regulations. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 7 The manager is considering providing a second stair lift within the home. All equipment had been serviced on a regular basis. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westwood DS0000014260.V296955.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 DS0000014260.V296955.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): 1,2,3,4 and 5 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. Prospective residents receive sufficient information to enable them to decide whether to come to live at Westwood. The manager undertakes a preadmission assessment of residents to ensure that the home can meet their needs. EVIDENCE: The statement of purpose and service user guide meet the National Minimum Standard and regulations. There is a copy of the service user guide in each room. All residents admitted to the home within the past twelve months were fully assessed by the manager prior to admission, with most residents in the home saying that the manager came to visit them before they came into the home. Evidence from representatives of residents and some residents showed that they had the opportunity to visit Westwood prior to deciding to make it their home. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 10 The manager said that he takes the statement of purpose and a brochure giving details of the home with him when he goes to assess prospective residents. The preadmission assessment forms the basis of the care plan, and the manager stated that he speaks to Health and social care professionals, relatives of the residents and the prospective resident prior to making a decision over whether the home can meet the residents’ needs. All residents have a statement of terms and conditions on their admission to the home and there was evidence of signed copies of this in resident’s files. Staff receive an induction course which in part addresses the care of the older person, and a few staff are in possession of the National Vocational Qualification level 2 in care. Westwood DS0000014260.V296955.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): 7,8,9,10 and 11 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. Although residents appear well nourished and cared for, documentation provided does not support the care that is being given or identify all the needs of the resident. Moving and handling of resident’s was being undertaken in an inappropriate manner but measures have since been taken to address this and ensure the safety of the residents. EVIDENCE: All residents have a care plan, which documents the needs of the resident and the care to be given to meet these needs. However many of these care plans did not fully address the needs of the resident as detailed in the preadmission assessment and some did not show current or changes of need. There was no on-going assessment relating to moving and handling requirement or managing continence, and in the case of one resident who had been prescribed cream, no acknowledgement in the care plans of how, when or where it was to be applied. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 12 Care plans did not indicate when a residents needs increase. Although care plans had been signed as being reviewed regularly there was no evidence that the current care needs had been identified or documented during these reviews. There was no evidence of the resident participating in either the formation or review of the care plan. Risk assessments were in place, but these had not been reviewed regularly. Care plans were not detailed enough to ensure that the care required would be given correctly. On the day of the inspection there was no moving and handling equipment within the home and care assistants had not received recent training in this. Two residents requiring the use of moving and handling equipment were seen to be moved in an inappropriate manner by care assistant. However, an immediate requirements letter was sent to the provider and information received from the provider was that within three days of the inspection he had purchased a hoist and other moving and handling equipment with staff having been given full training in the use of this and moving and handling. Care plans must identify how this equipment is to be used when moving these residents and also show ongoing mobility needs of all residents. One resident has pressure damage but the manager said that district nurses were involved in the care of this. Evidence of this was seen in the care plan. There was evidence that GPs and other health care professionals are contacted as required, and the home appeared very proactive in this. Residents are accompanied on hospital appointments if their relatives cannot do so. An optician and chiropodist visit the home, but the pre-inspection questionnaire states that a dentist is only access if the GP refers the resident. The manager must ensure that a dentist is available for residents to visit. A physiotherapist visits the home when referred by the G.P. All residents appeared well nourished and clean and tidy, the care plans include a daily diary and nutritional care plan, with evidence of monthly weights being undertaken on some residents. Residents spoken with and questionnaires received by CSCI showed that residents were happy with the care given and that they received medical support when it was required. It was evidenced both in the care plans and on the day of inspection, that instruction given by GP’s and any changes of medication were addressed promptly. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 13 One relative stated that ‘I have nothing but praise for the manager and staff for the care of my mother’ and ‘They genuinely care about their elderly residents’. Most relatives of residents confirmed that the staff inform them promptly of any concerns relating to the resident and inform them when a doctor has visited, however one relative was concerned that they had not been informed when their relative in the home fell and was injured. One questionnaire returned expressed some dissatisfaction about the standard of personal care of a resident, but the resident stated that ‘I don’t like the staff to fuss over me’ and intimated that at times she refused personal care. All residents said that the staff were polite, knocked their doors prior to entering and did not disturb them when they had visitors. Relatives, some of whom stated ‘The staff offer tea when we arrive but leave us to talk in private’, reinforced this. Residents confirmed that their bells were answered promptly both day and night and that night staff ‘Pop their heads in to make sure we are OK several times during the night’. There were no complaints regarding the laundry and residents said that their clothes were always returned ‘fairly quickly’. Ministers of religion are accessed as required and a layperson from a church visits regularly to give communion to one resident. All medical examination takes place in the resident’s own room. Medicine administration records were seen, in the majority of cases, to have been signed following administration and there were policies and procedures relating to the receipt and disposal of medication, including a policy addressing self-medication. All residents have a lockable drawer which can be used to store medicines should they wish to self medicate. No residents are selfmedicating at present. Medication records identified that one resident undertakes blood sugar monitoring, and there are instructions for staff on the action to take if the blood sugar does not fall within certain parameters, these include the instruction to contact the diabetic nurse. This resident administers her own insulin although the staff draw it up for her using an insulin pen. Staff have received training relating to this. All staff that administer medication have undertaken training and this training is on going, being supplied by the pharmacist who provides the home with medication. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 14 There was an on-going error in the recording of a drug, which is being treated as a controlled drug. This has been recognised by the home and the manager is trying to rectify this. However it is recommended that in future weekly drug counts and reconciliation take place to avoid a reoccurrence. Residents can remain in the home when very ill, unless transfer to hospital is recommended by the GP. Testimonials of relatives of residents who have died showed that the home has provided a caring environment and looked after the resident well. The manager stated that District and Macmillan nurses provide the nursing care to the very ill residents. Westwood DS0000014260.V296955.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 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. The quality of life enjoyed by residents would benefit from more variety in both the activities and the menu offered. EVIDENCE: Residents confirmed that they could choose what time they get up and go to bed and that they had a choice of whether to take part in the activities offered. Activities taking place in the home mostly consist of board games, bingo, videos and a selection of books. Staff spend one to one time with residents and play chess with one resident. Staff assist residents to use the garden and musical entertainment is brought into the home once a month. Relatives spoken with said that residents often choose not to take part in the activities offered, whilst some residents said ‘there is not much to do’ and ‘sometimes it is boring but staff do come and talk’. There is an informal, homely atmosphere and staff do many of their routine tasks in the lounge area and include residents in the conversation or encourage them to help with folding serviettes etc. An activities programme is in place but this needs to be formalising to address not what has taken place but what is to take place. Some records of which residents take part in activities are in the care plans, but these require expanding. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 16 There is an open visiting policy with visitors saying that they are made welcome when they visit and the staff and the manager keep them informed of what is taking place with the resident they are visiting. There is a well-balanced menu consisting of plain cooking, mainly incorporating such meals that would appeal to the older person. However although choices are available they are not written on the menu, staff saying they are aware of what individual residents like or dislike. However residents must be aware of choices available. There was evidence that all residents are asked what they would like to eat and a menu board is displayed in the dining room. Records of residents who choose to have a meal different to that which is on the menu must be kept. Residents said that they could choose what they want for breakfast and a cooked breakfast is available if they wished for one. They also confirmed that they could have snacks at any time and sandwiches etc during the night. Most cakes and puddings are bought in, and there is some fruit on the menu. The manager must adjust the menu to take into account the different seasons and try to use vegetables in season. Residents and visitors made mainly positive comments about the food, most residents were pleased that soup is served at lunchtime and all said that they had plenty to eat. They also said that if they liked something the manager would provide this. There was sufficient dried and frozen food and some fresh food in store. The environmental health agency visited the home, few recommendations were made and the majority of these have been complied with. Recording of fridge and freezer temperatures showed that the fridge temperature was above the recommended parameters and the manager must address this. The freezer was in need of defrosting. The kitchen was very clean, new flooring has been put in place and all care assistants who work in the kitchen have a current food hygiene certificate. Residents can eat their meals in the dining area or in their rooms, however care must be taken to ensure that tables and trays are laid attractively with the necessary china and cutlery. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 17 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): 16,17 and 18 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. Residents are aware of how to make a complaint and staff are aware of their role in the protection of those in their care. EVIDENCE: The complaints policy meets the standard and the regulations. All residents were aware of how to make a complaint and said that ‘the manager will always put things right’. There was no evidence of any documentation relating to any complaints and the manager said that if there are any concerns he addresses it verbally to the resident’s satisfaction. However a file in which to keep any formal written complaints, and the manner in which these are addressed, is in place. Residents are assisted to obtain financial and legal advice and the manager has access to an advocacy service. Residents can participate in the civic process by the use of postal votes. All staff received training in the protection of the vulnerable adult when they commence work at Westwood and the manager and some senior members of staff have undertaken formal training in this and the associated protocols. It is recommended that this is updated and cascaded to all staff. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21,22,23,24,25 and 26 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. New carpets, redecoration and an increase in the tidiness and cleanliness within the home has improved the environment for residents. Continuing attention to detail and improvement will result in Westwood becoming a very pleasant home. EVIDENCE: Since the last inspection there has been much improvement within the environment of the home. Tidiness within the home has increased and some new carpets and curtains have been put in place. Redecoration has taken place over much of the home. The garden is always well maintained and the exterior of the home has been repainted. Minor maintenance has been undertaken. There were some areas, which require attention, and these include carpets renewing in some of the rooms and on some stairways, the lounge carpet appears worn. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 19 Paving slabs around the washing line in the garden have become displaced and this must be attended to as they could cause an accident. The lounge area incorporates a dining area and leads directly onto the garden; the home provides a stair lift and a shaft lift therefore enabling all residents to access all parts of the home. There are sufficient assisted baths to meet the needs of the residents and bathrooms were in a clean condition. Residents’ accommodation is homely and they are encouraged to bring in personal possessions. Some residents’ rooms still need to have a locked facility for residents to be able to store personal items of value, this is being attended to. All doors are furnished with locks, with residents being given keys within the auspices of a risk assessment. Records of those residents who are unable or do not wish to have keys must be in place. The temperature of the water in resident’s rooms and bathrooms are checked and recorded on a monthly basis, and these are within recommended parameters. The home has been assessed by a qualified occupational therapist and recommendations made have been addressed. The kitchen is clean but a formal cleaning schedule needs to be put in place, a recent environmental health report made some recommendations, which need to be addressed. The laundry floor will require new impermeable flooring and this must be added to the maintenance plan for the home. The home is clean and in general no odours were noticed. However two rooms require attention and this was discussed with the manager. There are adequate supplies of paper towels, aprons and gloves in the home and there are infection control policies in place. A new dishwasher has recently been purchased. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. Work has been undertaken to put staff training in place. However not all staff have completed the induction training and some personnel files do not include the necessary documentation required to safeguard residents. EVIDENCE: There has been some turnover of staff since the last inspection and although the off duty rota indicates that there are sufficient staff on duty for the number of residents, some staff said that they felt pressurised to work extra hours to cover shifts. However new staff have been employed. Examination of personnel files showed that some do not include two written references for staff and these must be obtained prior to staff being employed by the home, it was also noted that staff when staff commenced work following receipt of the POVA first check but whilst waiting for the CRB, the manager does not always ensure that a specific member of staff supervise new staff. This was discussed. Most staff have induction training on commencing working at the home, although some members of staff have not yet completed this. and several staff have had medication training. Protection of the vulnerable adult training must be included in the induction training. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 21 Two members of staff (18 ) have the NVQ 2. This has to be increased and the deputy manager must obtain an NVQ qualification. Training records are in place. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. Residents have the opportunity to make their views of the service offered by the home known. The CSCI does not receive notification of events affecting residents and staff supervision has not taken place at intervals detailed in the standards, this could affect the wellbeing of the residents. Servicing and monitoring of equipment protects the health and safety of the residents and staff. EVIDENCE: The manager Mr Sadek has owned and managed the home for the past eighteen years. Although registered by the CSCI he has not undertaken any management training but does undertake all mandatory and training in the care of the residents. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 23 There is evidence of good rapport between residents, staff and management. Relatives of residents that visit the home stated that ‘It’s a nice home, very caring and supportive’, ‘Staff make us feeling welcome and keep us informed of any changes in Mum’s needs’, ‘Mr Sadek and his staff really care about the elderly people in the home’, ‘There is a lovely atmosphere in the home’ and ‘I felt at home here as soon as I came to live her’. Viewpoints from residents have been sought by the home, with the manager having given questionnaires to all residents relating to life within the home. He has made changes within the home on the basis of responses received. It is recommended that health and social care professionals are approached for their opinions on the service that the home provides. The inspection report is kept in the main hallway and is available to all people coming into the home. The business plan for the home has been seen on a previous occasion and appeared to be in order. The manager is not appointee for any resident although he does collect resident’s pensions for them. Records relating to personal allowances and fee payments were in place with receipts for personal allowance expenditure in place where applicable. The manager has set up a bank account for one resident. The majority of staff are receiving formal supervision, the manager must ensure that this takes place at a frequency as stated in the National Minimum Standards. All certificates relating to utilities and the servicing of equipment were in place. Risk assessments around the home were in place and have been reviewed, and staff have received fire and first aid training. Regulation 37 reports, which relate to death, serious illness or any other event, which affects the residents, have not been received by the CSCI and the manager has stated that he will commence these. All policies and procedures have been updated recently. All window restrictors were in place and secure, one of the French Windows in an upstairs room was discussed with the provider, although the restrictor was in place there was a query over whether the distance allowed was too great. Staff stated that they were aware of COSHH data and there was evidence that this was available. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 24 Staff had not undertaken moving and handling training since 2004, an immediate requirement relating to this and the provision of moving and handling equipment was made, and the manager complied with this within five days of the inspection taking place. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 2 Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Reg 15 Requirement Timescale for action 01/09/06 2 OP12 Reg 16 (2)(m)(n) 3 OP24 Reg 16(2)(c) 4 OP29 Reg 18 & 19 Sched 2 That the service user plan of care accurately reflects the current needs of the service user and the method of addressing these needs including any equipment to be used. That the plan of care is formed and reviewed in consultation with the service user. That a programme of activities is 30/10/06 devised and regular records kept of activities provided. This was a previous requirement (October and April 2005) That carpets are replaced those 01/11/06 areas discussed with the manager and that bed bases in most areas are replaced. (This was a previous requirement April, June and October 2005) That no member of staff is 01/09/06 employed prior to two written references having being obtained. That newly appointed staff who have the POVA First but awaiting CRB work only under supervision of a specific staff member and undertake an induction course. DS0000014260.V296955.R01.S.doc Version 5.2 Westwood Page 27 5 OP31 Reg 37 6 OP38 Reg 23 (4) Reg 13(4) That the manager supplies the 30/08/06 CSCI with reports detailing any death, serious illness, serious injury or any event including theft or burglary or misconduct of staff that could affect the wellbeing of the resident. The manager ensures that all fire 30/08/06 doors are kept free from obstruction. That all environmental health agency recommendations are undertaken and that all other matters relating to health and safety and infection control addressed in the main body of the report are acted upon. 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 3 4 Refer to Standard OP9 OP15 OP24 OP26 Good Practice Recommendations That auditing of controlled drugs takes place weekly in order to facilitate tracing if errors have occurred. Those choices of menu are made clear and records are kept of those service users who choose alternative meals. That risk assessments are undertaken for those service users who have keys to their room doors and records of service users who do not wish to have keys are kept. That block soap is not left in communal bathrooms. Westwood DS0000014260.V296955.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 DS0000014260.V296955.R01.S.doc Version 5.2 Page 29 - 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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